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MEDICO-LEGALANDTOXICOLOGY

MODULE

PHASEII

StudentHandBook2017

Faculty of Medicine University of Kelaniya

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CONTENTS

Page

1. MessagefromtheModuleCommittee 22. AimandObjectives 3,4

3. Intendedlearningoutcomes 54. Learningresources 65. Coursecontents 76. AssessmentofMedico-LegalModule 117. Self-assessment 138. Suggestedreadingmaterials 13

“Thosewhohavedissectedorinspectedmanybodieshaveatleastlearnedtodoubt,whilethosewhoareignorantofanatomyanddonottakethetroubletoattendtoit,areinnodoubtatall”GiovanniMorgagniFatherofMorbidAnatomy

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MESSAGEFROMTHEMODULECOMMITTEEDearMedicalStudent,TheMedico-legalandToxicologymoduleisconductedduring4thyearoftheMBBSmedicalcourse.Itwillbetheonlyopportunityforyoutolearnaboutthemedico-legalresponsibilitiesofdoctors,ifyoudonotgoontospecializeinForensicMedicine.ThismoduleisdesignedforyoutogaintherequiredbasicknowledgeandskillsinForensicMedicinetofunctionasamedicolegalexpert.Furtheritincludesprogressindicatorswhichwillenableyoutoassessyourselfduringandattheendofthemodule.Itisadvisableforyoutofollowtheinstructionscarefullyandachieveyourlearningoutcomesattheendofthemodule.Ifyouencounteranydifficulties,youarewelcometoseekhelpfromthemembersoftheacademicstaffattachedtothedepartmentofForensicMedicine.BestWishes,Dr.P.ParanitharanChairperson,Medico-LegalandToxicologyModule

Medico-LegalModuleCommittee

• Dr.P.Paranitharan-DepartmentofForensicMedicine• (Chairperson)

• Dr.IndiraKitulwatte-DepartmentofForensicMedicine• (Co-Chairperson)

• Dr.NirmalaPerera-DepartmentofForensicMedicine

• Prof.PAS.Edirisinghe-DepartmentofForensicMedicine

• Prof.KithsiriGunawardane-DepartmentofParasitology

• Dr.ShalukaJayamanna-DepartmentofMedicine

• Dr.N.V.Luke-DepartmentofPharmacology

• Dr.AsiriRodrigo-DepartmentofPsychiatry

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ExtendedFaculty

• ProfessorRavindra Fernando - Senior Professorof ForensicMedicine&Toxicology, Faculty of

Medicine,Colombo

• Dr.L.B.L. deAlwis – Chief JudicialMedicalOfficer (retired), Instituteof ForensicMedicine andToxicology,Colombo

• Mr.PalithaFernando–AttorneyGeneralofSriLanka(retired)

• Dr.P.R.Ruwanpura–ConsultantJMO,TeachingHospital,Karapitiya

• Dr.HandunWijewardena-ConsultantJMO,ColomboNorthteachingHospital

• Dr. Angelo de Alwis – Consultant Psychiatrist, Forensic Psychiatry Unit, National Institute ofMentalHealthSriLanka

• Dr.JayaniWeeraratne–ForensicOdontologist,InstituteofLegalMedicine&Toxicology,Colombo

AIMToenablestudents togatheradequateknowledgeandskills toattendtotheirMedico-Legaldutiesefficientlywhentheypracticeasdoctors.

OBJECTIVESOFTHEMEDICO-LEGALANDTOXICOLOGYMODULE

Attheendofthemodule,youshouldbeableto;(1) Describedifferentmedico-legaldutiesrequiredofadoctorworkinginthefollowingroles:-

o MedicalOfficerintheout-patientdepartmentofahospital.o HouseOfficerinchargeofawardinahospital.o SpecialistinanyfieldorDirectorofahospital.o DistrictMedicalOfficerorMedicalOfficer(Medico-legal)o GeneralPractitionero Doctorworkinginanyothercapacity.

(2) Outline the medico-legal frame work and the relevant sections of the Penal Code, Criminal

ProcedureCodeandTransplantationofHumanTissueActofSriLanka.

(3) Identify, record, formanopinion and report ondifferent types of injuries anddescribe theirmedico-legalsignificance.

(4) Describethedifferentinjurypatternsandcircumstancesunderwhichtheyoccur.

(5) Explaintheconceptofdeath,makethediagnosisofdeath,issueoftheCertificateofCauseof

Deathanddescribetheprocedureinvolvedindisposalofdeathandexhumation.

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(6) Describethechanges,whichtakeplaceinabodyafterdeathandtheirmedico-legalsignificance.

(7) Performpostmortemexaminations,recordobservations,formulatecausesofdeath,carryout

furtherinvestigationsanddrawconclusions.(8) Examine victims and suspects in cases of assault, accidents, sexual offences, abortion, child

abuse,wifebattery/genderbasedviolence,elderabuse,torture,drug&alcoholabuseandanysuchpersonthattheCourtdirects.

(9) Fillrelevantmedico-legalreportsandgiveoralevidenceinthecourtoflawasanexpertwitness.(10) Explainthemethodsinestablishingtheidentityofthedeceasedortheliving.(11) Visitandexamineasceneofcrimewithateam,collectevidenceandformulateconclusions.(12) Describe the medico-legal investigations of sudden, unexplained, unexpected, obscure and

suspiciousdeaths.(13) Describethemedico-legalinvestigationsofdeathsduetoaccidents,suicides,homicides,civiland

criminalnegligence.(14) Describemedicolegalimportanceofmentaldisorders.(15) Developanunbiasedattitudetowardssocietyespeciallywithregardtovictimsandsuspects.(16) Cultivateattitudesnecessarytofunctionasamemberofateamininvestigationofcrime.(17) Identifythetypes,circumstances,principlesofmanagementofcommonpoisonsinSriLanka. TheseobjectiveswillbecoveredintheMedico-legalModuleandduringthemedico-legalrotationinthefourthyear.

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IntendedLearningoutcomesofthemoduleinrelationtothefacultyoutcomes

FacultyOutcomes Broadcontentareasareincludedunderfollowing

Doctorasapractitioner

Clinicalskillsandpatientmanagement

• Historytakingphysicalexaminationandmedico-legalmanagementofclientsproducedbypolicewithanMLEFormagistrateorderandotherwardreferrals.

• Performpost-mortemexaminations• Requestlaboratoryandradiologicalinvestigationasappropriate.

Communicationskills

• Verbalcommunicationwithvictims,perpetrators,lawenforcementauthorities,healthcareworkers,mediaandthepublicindealingwithmedico-legalissues

• Writtencommunicationwithlaw-enforcementauthoritieshealthcareofficialsandpublicindealingwithmedico-legalissues

Populationhealth&healthsystems

• Workingwiththeexistinghealthsystemindealingwithmedico-legalissues

Informationmanagement

• Retrievinginformationfromrelevantsourcesforevidence-basedpracticeinrelationtomedico-legalduties

• Accuratedocumentationandrecord-keeping

Doctorasascientist

ScientificbasisofMedicine

• Normalstructureandfunctionofeachanatomicalarea,• Mechanismsofcausationofinjuries,• Medico-legalimplicationsofdifferenttypesofinjuries,• Expertevidenceinthecourtoflaw,• Pathogenesisofdiseases,theiraetiology,pathology,• Investigationsandcontributioninarrivingatacauseof

death.• Toxicologicalanalysisofdifferenttypesofpoisonsand

medico-legalaspects.Criticalthinking&research

• Followingprotocols/guidelinesandcomplywithevidenceinmedico-legalpractices

Doctorasaprofessional

Professionalvalues,attitudes&ethics

• Possessingattributeslikehonesty,integrityandtruthfulnessinperformingmedico-legalduties

• Maintainingconfidentialityandprivacyinmedico-legalexamination

• Identifyingownlimitationsandseekforhelpinmedico-legaltaskswhereappropriate

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LEARNING RESOURCES

I.Lectures

YouwillbegivenanopportunitytolistentolecturesonthemostimportantaspectsinForensicMedicineandToxicology.ThePowerPointpresentationsusedforselectedlectures(includingrelevantphotographs)willbeavailable.

II.Handouts

HandoutsonthelecturetopicswillbeavailableintherelevantsectionoftheVirtualLearningEnvironmenttogetherwithadditionallearningmaterial.

III.VideoDemonstrations

• Theprocedureofperformingapostmortemexaminationwillbedemonstratedwithadocumentary

filmduringthelectures/clinicalappointment.• Theprocedureofperforminganexhumationwillbedemonstratedwithanotherdocumentaryfilm

duringthelectures/clinicalappointment

IV.TutorialsThe tutorialswill be arrangedon selected important topics. You are expected to attend all tutorials. Theattendancewillbemarked.Thesatisfactoryattendanceoftutorialsisaprerequisitetositthefinalmoduleexam.V.PostmortemDemonstrationsandWardClasses

Duringtheclinicalappointmentyouwillbeabletoobserveandalsotoassistinacaseofpostmortemandexaminationofpatientswithmedico-legalproblems.

VI.FixedLearningMaterials

Museumspecimensofsofttissues,bonesandphotographsofvariousmedico-legalcaseswithdescriptionsareavailable(indigitalformandhardcopies)atthedepartmentofForensicMedicineandthefacultyForensicMedicinewebsite.Inadditionasetofselectedspecimensandphotographswillbedisplayedinthemuseumwithquestionspertainingtomedicolegalissuesorthevirtuallabwouldbeutilizedtodemonstratethesamesetofforensicmaterials.VII.E-LearningMaterialSelectede-learningmaterialsareavailableinthenewlyestablished‘VirtualLearningEnvironment’whichcanbeaccessedfromthedepartmentofForensicMedicinewebsite.VIII.QUIZAfriendlycompetitionamongdifferentgroupsofmedicalstudentstopromoteactivelearningwillbeheldduringmodulehours.IX.Self-studySelf-study is strongly recommendedwithmuseum specimens,medico-legal reports andmedico-legal textbooksavailableintheForensicMedicinelibraryandtheMainlibrary.

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Fixedlearningmaterialsbasedonphotographsofmedico-legalrelevanceinquestionandanswerformatisavailableintheForensicMedicineMuseum.

COURSECONTENTS

Thecoursecontentsarelistedbelowtogetherwithakeythatguidesyouindifferentiatingbetweentherequiredcoreknowledgeandskillsandareasthatare‘’nicetoknow’’*KEYTOBETTERUNDERSTANDINGOFTHECOURSECONTENTS.

(A) Comprehensiveknowledgeofspecifiedareaandcompetencyinspecifiedmedico-legalwork(B) Knowledgeofthebasicprincipleswithabilitytoidentifywherereferralisneeded(C) Nicetoknow

CoreKnowledge=(A)+(B)

(1)IntroductiontoForensicMedicine(a)DefinitionandScopeofForensicMedicine-B(b)AimsandObjectivesoftheModule-B(c)Whatweexpectfromthestudents-B

(2) MechanicalTrauma(a)Typesofinjuries,definitions,featuresandcausations-A(b)Interpretationofinjuriesinrespectof;-Ai.Causativeweaponii.Circumstancesofcausation

(accidental/suicidal/homicidal/self-inflicted/fabricated/defenseetc.)iii.Datingofinjuriesiv.Ante-mortemandpostmorteminjuries

(3) RegionalInjuries

Medico-legalsignificance,sequelae&complicationsinrelationtofollowingregionsofthebody-A(a)Head/face

(b)Neck(c)Chest

(d)Abdomen(e)Pelvis/genitals(f)Limbs

(4) Medico-legaldocuments&categoryofhurtinrelationtoPenalCodeSec.311

(a) MLEF-A(b) MLR-A(c) Givingoralevidenceasexpertwitness-A(d) Dyingdeclaration,Testamentarycapacity-B

(5)Road-TrafficAccidents

Injurypattern,methodofcausationandpreventionofinjuriesin;(a)Pedestrian-A

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(b)Driver,frontseatpassenger,occupant-A(c)Motorcyclist/PillionRider/Pedalcycler-A(d)Investigationinacaseof‘HitandRun’-A(e) Investigationofbody foundonorby the rail tract. (Accidental, suicidal,homicidalorpostmortem

disposal)-B(6) FirearmInjuries

(a)Typesoffirearms(smoothboreandrifled),mechanismsoftheiroperationandcausationofinjuries-A

(b)Identifyentry/exitwounds-A(c)Estimaterange/direction/angleofdischarge-B(d)Circumstances–homicide/suicide/accident–B

(7) BlastInjuries (a) Whatcausesblastinjuries-A(b) Componentsoftheblastandtheinjuriescausedbythosecomponents-A(c) Interpretationofinjuriescausedbyablast-A(d) Investigation/Visittoasceneofmassdisasterfollowingabombexplosion-A(e) Problemsencounteredattheautopsyofvictimofamassdisasterfollowingabombexplosion-A

(8) InjuryfromPhysicalAgents

(a)Heat&cold(general)-B HyperthermiaandHypothermia Bothclinicalandpostmortemfindings (b) Burns-A-Flameburns,

-Moistburns,-Corrosiveburns

(Identificationofburnsfromtheirfeatures)Medico-LegalInvestigationofacharredbodyfoundinaburntdownhouseHeatartifacts

(c) Electrocutioninjuries-AAppearanceofaninjuryMechanismofdeathPostmortemfindings

(d) Lightning-AMechanismofcausationofinjuryPostmortemfindingsMechanismofdeathInvestigationinacaseofdeathduetolightning

(9) PhysicalandSexualChildAbuse (a)Typesofchildabuse-A(b)Diagnosisofchildabuse-A

(c)Classicalclinicalfeatures/autopsyfindingsincaseofchildabuse-A(d)Differentialdiagnosisofchildabuse-A(e)Caseconference–B

(10)Battering&Torture (a)Circumstancesofbattery&torture-B

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(b)Methodsused-A(c)Diagnosisofbattery&torture-A

(11)SexualOffences

(a) LawsonRape/Incest/Unnaturaloffences/Gravesexualoffence-A(b) Clinicalexaminationofavictimofrape,ethicalaspect&thecollectionofsamples-A(c) Interpretationofinjuriesfoundonavictimofrape-A(d) Clinicalexamination&collectionofsamplesofanassailant-A(e) Examinationofvictim&assailantinacaseofanalintercourse-A(f) Examination,interpretationofinjuries&reportinginacaseofchildsexualabuse–A

(12). Abortion

(a)Definition(MedicalandLegal)-A(b)LawsrelatedtoabortioninSriLanka-A

(Sec.303ofthePenalCode) (c)Methodused-A (d)Complication&theCauseofDeath-A(e)Diagnosisofcriminalabortion–clinical&atautopsy-A

(13). Infanticide

(a)LawsrelatedtoinfanticideinSriLanka-A(b)Diagnosisoflivebirthandstillbirth-A

(c)Estimationofthematurity-B(d)Actofcommissionoromission-A(e)Autopsyinacaseofsuspectedneonataldeath-B(f)Examinationofthemother-B

(14) Death

(a)Definitionofdeath(Somaticdeath/moleculardeath/braindeath)-B(b)Diagnosisofdeath-A

(c)Certificationofdeath,writingdeclarationofdeathform-A(d)Disposalofdeath-B

(15) InquirerintoSuddenDeathsandInquestProcedure (a)DefinitionandrelevantsectionsofCriminalProcedureCode-B(b)Typesofdeaththatneedaninquest-A

(c)Inquestprocedure-A(d)Dutiesofinquirerintosuddendeath-A(e)Doctor’sroleinaninquest-A

(16) PathologicalAutopsy

(a) Requirementsforpathologicalautopsy–A(17) Medico-legalautopsy

(a)Aims&objectivesofmedico-legalautopsy-A(b)Proceduretobefollowedinmedico-legalautopsy–A

(18) TransplantationofHumanTissueAct (a) Basicconceptsrelatedtotheaboveact–A

(19) SceneofCrime

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(a)Whatisasceneofcrime-A(b)Who,Why,When,tovisit-A

(c)Recordandcollectevidenceatascene-A(d)Dispatchofabodyfromthescenetothemortuary-A

(20) Exhumation

(a)Legalrequirement-A(b)Howtocarryoutanexhumation-B

(21)Postmortemchangesinabody

(a)Earlychanges-A(b)Latechanges-A

(c)Remotechanges-Adipocere,Mummification&Skeletonisation-A

(22) Estimationoftimesincedeath (a)Medicalmethods-A

• Postmortemchanges• Cessationofphysiologicalfunctions

(b)Non-medicalmethods(circumstantial)-A(c)Limitationsofavailablemethods-A

(23)Identificationofliving&dead(a)Externalfeatures-A(b)ClothingandPersonalbelongings-A(c)Dentition-A(d)Fingerprints-A(e)IntroductiontoForensicAnthropology-B(f)SpecialTechniquese.g.VideoSuperimposition,FacialReconstructionetc.-B(g)DNAprofiling–B

(24)Suddenadultdeath(a)Definition-A

(b)Causesofsuddendeath-A(c)Postmortemfindingsofsuddendeath-A(d)Conceptofobscure&negativeautopsy-B

(25)SuddenInfantdeath(a)Definition-A(b)PostmortemexaminationofSuddenInfantDeathSyndrome–B

(26)Starvation&Neglect(a)Causes&circumstances-B

(b)Postmortemfindings–A

(27)Asphyxia (a)Definition-A(b)Features,Pathophysiologyofvarioustypesofasphyxia-A(c)Differentmodesofasphyxia-A(d)Mechanismsofdeath-A(e)Postmortemfindings-A(f)InvestigationofAsphyxialdeaths-A

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(28)Alcohol (a)Stagesofintoxication-A(b)Clinicalexaminationfordrunkenness-A (c)Othermethodsavailabletoestablishdrunkenness-A

(d)Effectsofalcoholontheabilitytodrive-A(e)Lawsrelatedtodrunkenness-A(f)Differentialdiagnosisofalcoholintoxication-A(g)Suddendeathduetoalcoholabuse-B

(29)CollectionofTraceEvidence

(a)Samplecollection-types&methodsused-A(b)Examinationofbloodstains&otherstains-C

(30)Deathsduetosurgery&anesthesia

(a)Definition-B(b)Howtoconductanautopsy-A(c)Specialinvestigations-B

(31)DutiesofMedicalOfficersinthefollowingroles;

(a)AMedicalOfficerintheout-patientdepartment-A (b)AHouseOfficerinchargeofawardinahospital-A

(c)ASpecialistinanyfieldoradirectorofahospital-B(d)ADistrictMedicalOfficerorMedicalOfficer(Medico-legal)-A(e)AGeneralPractitioner-A(f)ADoctorworkinginanyothercapacity-A

(32)IntroductiontoForensicPsychiatry-B

(33)Basicsofcriminallaw,criminalresponsibility,culpablehomicide/murder–B(34)IntroductiontoForensicOdontology-B

(34)ForensicToxicology

(a) Agrochemicals(OP,Paraquat&others)-A(b) Metalsandnonmetals-A(c) Corrosives-A(d) Irrespirableagents-B(e) Plantpoisons-A(f) Therapeuticdrugs-A(g) Envenomationbyanimals-A(h) Principlesofmanagementincasesofpoisoning-A

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ASSESSMENTS

KnowledgeonForensicMedicineandToxicologywillbeassessedin

1. ContinuousAssessment82. Unit4ofthe2ndexaminationforMedicaldegree

CONTINUOUSASSESSMENT

CA8Consistsof

• StructuredEssayQuestions• Practicalcomponent

CA8contributewith10%oftheUnit4examinationmarks.ThepracticalcomponentwillbebasedontheEvaluationofaMedico-legalExaminationofa livingpersonduringtheForensicMedicineClinicalattachmentinthecourseof4thyear.

UNIT4EXAMINATION

Unit4examinationconsistsof

• StructuredEssayQuestions• MultipleChoiceQuestions/Singlebestresponse• OSPE

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SELFASSESSMENT

Attheendofthemoduleandclinicalappointment,thestudentshouldbeabletoassesshim/herself.Ifhe/shefindshim/herselfatalowerrankingthepersonshouldtakeappropriateremedialmeasurestocorrecttheshortcomings.

SUGGESTEDREADINGMATERIALS

• Simpson’sForensicMedicine;Eds:JasonPane-James,RichardJones,StevenKarch,JohnManlove13thEdition

• MargaretMStark:ClinicalForensicMedicine,Aphysician’sGuide2ndEdition• PekkaSaukko&BernardKnight:Knight’sForensicPathology,:3rdEdition• VincentJMDiMaioandZuzannaEDana:HandbookofForensicPathology;2ndEdition• PathologyoftraumabyJKMason&BNPurdue3rdEdition1999• ForensicMedicineClinicalandPathologicalAspects.JasonPane-James,AnthonyBusuttil,

WilliamSmock2002• Prof.RavindraFernando:ManagementofPoisoning;4threvisededition• LBLDeAlwis:LectureNotesinForensicMedicine;volumeI,II,III,IV

S.Agree3marks

Agree2marks

Disagree0marks

Myoveralllevelofknowledge,skills&applicationinForensicmedicineisimprovedduringthemodule&clinicalappointment

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DepartmentofForensicMedicine

FacultyofMedicineUniversityofKelaniya

2017