When Injuries Speak:

1. When Injuries Speak: Forensic Wound Identification & Documentation of Suspected Abuse & Neglect Daniel J. Sheridan, PhD, RN, FNE-A, SANE-A, FAAN Associate Professor, Johns Hopkins University, School of Nursing Forensic Clinical Nurse Specialist

2. 4N6 RN • Forensic Nurse • Forensic = Pertaining to the Law • International Association of Forensic Nursing • www.iafn.org • 1-410-626-7805

3. Objectives • In this session participants will learn: • Correct forensic terminology related to abuse, neglect • Differentiate physical indicators of intentional versus accidental trauma • Identify patterned injuries and patterns of injury to help differentiate accidental from intentional injury • Discuss the role of medications in injury presentation • Demonstrate the ability to document in writing using correct forensic terminology and photographically violence-related findings in medical records • Apply principles of forensic evidence collection

4. Forensic Terminology In order to accurately assess, document, and investigate suspected abuse, one needs to learn the correct use of many common forensic terms. In the following session forensic definitions will be presented along with photographic samples of the defined injury. http://www.cmstraining.info/pubs/provider_training.aspx

5. Abrasion • A wound caused by rubbing or scraping the skin or mucous membrane.

6. Sample – clarify fell versus found down • Mrs. J. Jones reportedly found on tiled bathroom floor at 2315 hours by direct care staff, R. Gilbert and J. Gentile. • Mrs. J. Jones reportedly fell at 2315 hours witnessed by direct care staff, R. Gilbert and J. Gentile.

7. Abrasions are common injuries incurred from accidental falls, however, certain types of abrasions are consistent with intentional mechanism of injury. For example, if a person is laying supine and is dragged by her feet along any rough surface (carpet, sidewalk, street) you would expect to see an abrasion along the mid- spine. If a person is dragged supine by his feet with any sort of back and forth movement, the abrasion would cover much of the mid-back from side to side as previously pictured. Abrasion

8. Avulsion • The tearing away of a structure or part. Often seen as a partial avulsion.

9. Avulsion • Avulsion: • The complete tearing away of structure or part. • Often seen as a partial avulsion • A skin tear Photos © 2006. Used with permission of Daniel J. Sheridan, PhD, RN. Do not reproduce photographs without permission.

10. Avulsion • Skin tears (partial avulsions) to the elderly most often occur to the arms and hands. For the skin to tear there must have been blunt and/or shearing force energies. • Skin tears in patients who are total care must have been inflicted by another person. • One needs to assess if the partial avulsion was truly accidental, the result of excessive force, or abuse by a caregiver.

11. Bruise • Blunt force trauma that results in a superficial discoloration due to hemorrhage into the tissue from ruptured blood vessels from beneath the skin surface without the skin itself being broken: • also called a contusion.

12. Contusion • A bruise: • Traumatic injury of tissue without breakage of skin; blood accumulates in the surrounding tissue producing pain, swelling, tenderness, and discoloration.

13. Cut • See incision.

14. Ecchymosis • A hemorrhagic spot or blotch, larger than petechia, in the skin or mucous membrane forming a non-elevated, rounded, or irregular blue or purplish purpuric patch. • Ecchymosis is not injury from blunt force trauma. It is NOT a bruise or contusion. • Ecchymosis is purpura usually in the skin or mucous membranes.

15. Ecchymosis • Ecchymosis in the elderly is often to the arms and/or hands. • Blunt force trauma to the mid face often results in the development of bilateral periorbital ecchymoses (raccoon eyes). • Discoloration from a bruise can be pulled by gravity downward. The downward discoloration is called ecchymosis while the discoloration at the point of blunt impact is called a bruise.

16. Hematoma • A localized collection of blood

17. Hematoma: A localized collection of blood from a broken blood vessel (s). Hematomais not a synonym for a bruise or a contusion. Hematoma

18. Hematoma • Many health professionals mistakenly call a bruise a hematoma and vice-versa. • While a hematoma may be imbedded within a bruise as a palpable mass, hematomas can be caused by non- traumatic means ie., a spontaneous blood clot to the brain.

19. Hemorrhage • The escape of blood from a ruptured vessel. It can be internal, external, or into the skin or other tissue.

20. Incision • An Incision =A cut. • A cut that is deeper than it is wide is a stab wound • A wound made by a sharp instrument or object (a sharp injury). • Scalpel, knife, razor, paper

21. Laceration • The act of tearing or splitting. A wound produced by the tearing or splitting of body tissue often from blunt impact, usually over a bony surface, that is distinguished from a cut or incision.

22. Incision • The inside edges of a sharp wound (cut, incision) are relatively smooth and equidistance in depth. • If a serrated knife is used, the inside edges may have a more scalloped appearance.

23. Laceration • Lacerations to the skin are usually jagged or stellate (star-shaped) in appearance. • The depth of lacerations is variable and often tunnels under the skin.

24. Lesion • Any pathological or traumatic discontinuity of tissue or loss of function of a part. • Broad term, including wounds, sores, ulcers, tumors, or other tissue damage.

25. Patterned Injury • An injury where one is reasonably certain an object caused the injury, or certain which object caused the injury and/or by what mechanism an injury was caused.

26. Coining & Cupping

27. Pattern of Injury • Injuries in various stages of healing, including new and old scars, contusions, fractures, wounds.

28. Petechia • Minute, pin-point, non-raised, perfectly round, purplish-red purpuric spots caused by intradermal or sub-mucous hemorrhage, which later turns blue and yellow.

29. Petechia • Petechia are caused by the rupture of capillaries. When blood is not allowed to leave the head/face because of occlusion or compression of the jugular veins, capillaries will burst in and around the eyes and face.

30. Pressure Ulcers – Closing Session

31. Puncture • The act of piercing or penetrating with a pointed object or instrument.

32. Purpura • Purpura is a hemorrhagic rash with leakage of blood into the tissue. • Often associated with bleeding or clotting disorders. Ecchymosis and petechia are forms of purpura.

33. Skin Tear • Skin tear: • See Avulsion Photos © 2006. Used with permission of Daniel J. Sheridan, PhD, RN. Do not reproduce photographs without permission.

34. Unexplained Injury • It is relatively common, especially for institutionalized elderly to hear from caregivers that they have no idea how the patient received her/his injuries. • All significant unexplained injuries to vulnerable patients should raise one’s suspicions of possible abuse or neglect.

35. Wound • A bodily injury caused by physical means, with disruption of the normal structures • contused w. - one which skin is unbroken • incised w. - one caused by cutting instrument • lacerated w. - one in which tissues are torn • open w. - one having free outward opening • penetrating w. - one caused by a sharp, slender object that passes through the skin into tissue

36. Documentation Pearls If you did not chart it……… You did not do it!!!!! Avoid personal opinion Avoid charting arguments with co-workers Avoid derogatory remarks about client, family, or other providers Write legibly, legibly, legibly, legibly

37. Forensic Documentation As verbatim as possible Do not sanitize Do not “medicalize” Avoid pejorative documentation Document excited utterances Document medical exceptions to hearsay

38. Avoid pejorative documentation Stop charting “refused” Stop charting “uncooperative” Stop charting “non-compliant” Stop charting “alleged” and “allegedly” Stop charting your feelings Stop charting your anger

39. Forensic Photography - 1 35 mm vs Polaroid vs Digital ISO 200 - ISO 400 Film is least expensive part of the investigation Frontal ID shot Rule of thirds Use different lighting

40. Serial Photography

41. Forensic Photography - 2 Photograph the environment - measure the room/furniture/equipment Color slides/tape measures/stick-ums Use a scale - ruler/coin/pencil One roll per client/patient - 12 exposure Match injury to object if possible

42. Standard Rulers Lightning Powder Company 1-800-852-0300 - Free Catalog www.redwop.com

43. Forensic Photography - 3 Make duplicate or triplicate prints Label all prints Client/patient name Client number Date of Birth Date/time of photo Name of photographer Physical location and body part location

44. Daniel J. Sheridan, RN, PhD • sheridan@quixnet.net • Home Office 6210 Fairbourne Ct. • Hanover, MD 21076 • 410-379-8577 410-379-8572 fax • Johns Hopkins University • School of Nursing, Room 467 • 525 N. Wolfe St • Baltimore, MD 21205 410-614-5301 • 410 - 955 - 7463 fax dsheridan@son.jhmi.edu