Role of the Forensic Physician (part 2)

1. Role of the Forensic Physician(part 2)

2. DIABETES • Types • Hypoglycaemia • Hyperglycaemia • Blood sugars • Insulin • Food

3. Examination Consideration should be given to recording:  pulse;  blood pressure;  temperature if indicated;  condition of skin surfaces;  appropriate examination of body systems;  mental state if appropriate. Investigations HCPs should perform an estimation of BG level (clean area of skin before testing with a non- alcohol wipe) with a blood glucose meter. If the detained person (DP) has their own device, witnessed self-testing may be conducted. The baseline level will inform the need for and frequency of further testing. It may be advisable in insulin-dependent diabetics to check the blood glucose levels more frequently during detention. Urinalysis may assist decision making in relation to reviews.

4. Management Plan A careful management plan should be detailed and shared with the DP, HCPs and custody staff. Particular care should be taken in those with complications such as drug intoxication, alcohol dependence or acute intoxication, head injuries and concurrent infections or complications, e.g. vomiting. Consideration should be given to the recommended frequency of BG testing for the following HCP review.

5. Hyperglycaemia If blood glucose >25mmol/l and there is evidence of impairment of level of consciousness/confusion or concurrent infection, then refer immediately to hospital. Safe practice would mean that the HCP should consider immediate hospital transfer for those DPs with a BG >30mmol/l.DPs with levels between 12-25mmol/l would normally be Fit to be Detained (FTBD), but an individual global assessment (this may include urinalysis) needs to be undertaken. It may be safer practice to maintain BG levels higher than optimal community levels to reduce vulnerability to hypoglycaemia during detention. In impaired consciousness, regardless of the BG reading, the HCP should carefully consider the need for hospital referral.

6. Diabetic Ketoacidosis (DKA) This may occur with hyperglycaemia. Typical symptoms of diabetic ketoacidosis include:  Vomiting;  Dehydration;  Deep laboured breathing;  Non ketotic hyperosmolar states should also be considered;  Confusion and sometimes even coma. Symptoms of diabetic ketoacidosis usually evolve over a 24 hour period, with the first sign often being hyperglycaemia. These symptoms of DKA with urine ketones of greater than 2 are an indication to admit as an emergency.

7. Hypoglycaemia If the HCP measures the BG 2-4mmol/l, they should administer 10g glucose as drink/gel/carbohydrate and review over the next 10 minutes when the BG level should be repeated. The HCP should remain with the DP during this time. 10g of glucose is available from 2 teaspoons sugar, 3 sugar lumps or 1 tube hypostop gel. For those able to swallow, after initial sugar the patient should follow up with complex carbohydrate containing food when they have recovered sufficiently. First line treatment for those unable to swallow or unconscious is 500 micrograms of glucagon IM, with IV glucose 20% second line if glucagon not available. (Note consideration of alcoholic or liver disease status It should be remembered that glucagon requires the liver to have stores of glycogen and so in alcoholic, or other liver diseases, it may not work.) The FP should remain with the DP until he is conscious. The DP may need to be transferred to hospital especially if there is a long acting insulin, long acting sulphonylurea, drugs or alcohol on board.

8. CS INCAPACITANT

9. CS INCAPACITANT • The most common crowd control agents ('CCA') are:- • o-chlorobenzylidene malononitrile (CS) • l-chloroacetophenone (CN,'Mace') • dibenzoxazepine (CR) • oleoresin capsicum (OC,'Pepper Spray')

10. CS INCAPACITANT TOXICITY These chemicals are irritant to the skin, eyes and upper respiratory tract. Their irritant effect stimulates tear secretion, hence the name "tear gas". In the majority of cases effects are short-lived and self-limiting. Severe cases are only likely to occur following exposure to high concentrations in confined spaces.

11. CS INCAPACITANT Onset and Duration: Virtually immediate onset, effects usually settle within 15-30 minutes after removal from exposure. Occasionally ocular and mucous membrane effects can last for up to 24 hours.

12. CS INCAPACITANT Eye: Blinking, lacrimation, pain, blepharospasm, conjunctival erythema and periorbital oedema. Nose: Discomfort or burning sensation, pain and rhinorrhoea. Mouth: Stinging or burning sensation, salivation, possibly nausea and vomiting.

13. CS INCAPACITANT Respiratory Tract: Sore throat, tight chest, coughing, sneezing and increased secretions. Bronchospasm and laryngospasm may occur. Pulmonary oedema may occur 12-24 hours later following excessive exposure. Patients with pre-existing respiratory disease (e.g. asthma, bronchitis) may be more at risk of severe effects. However, these gases are highly water soluble and usually dissolve in secretions before reaching the alveoli.

14. CS INCAPACITANT Skin: Burning sensation and erythema which usually settles within 24 hours. Prolonged exposure, particularly when clothing is wet, can produce chemical burns. Skin exposed to CR may become painful on contact with water up to 48 hours later. CN is a skin sensitiser and can produce allergic contact dermatitis (pruritus, weeping, papulovesicular rash) within 72 of exposure. Allergic contact dermatitis has also been reported following exposure to CS.

15. CS INCAPACITANT TREATMENT In the majority of cases effects resolve spontaneously within 15-30 minutes after cessation of exposure and medical treatment is usually not required. Reassurance is essential. The most important first line treatment is removal from exposure and removal of contaminated clothing (dry if possible) which should be sealed in plastic bags.

16. CS INCAPACITANT Medical personnel should wear gloves. Casualties should be placed in a well ventilated area, preferably where there is a free flow of air to ensure rapid dispersal of the gas. Usually tear secretions are sufficient to remove the chemical from the eye, but symptomatic relief may also be achieved by blowing dry air onto the eyes with a fan. Where ocular effects persist eye irrigation should be undertaken using isotonic saline (sterile water may be used in emergencies but it may cause transient corneal oedema following prolonged irrigation). Ophthalmological referral is indicated for patients with severe ocular effects.

17. CS INCAPACITANT The skin should be washed with soap and water if necessary. Further treatment is unlikely to be required. Any chemical burns should be treated as thermal burns. Topical steroids may be used for contact dermatitis. Patients with persistent respiratory symptoms should be admitted to hospital for observation. Humidified oxygen may provide symptomatic relief. Clothing may be decontaminated by washing in a conventional washing machine with a normal powder or liquid. The clothing should be washed several times before wearing to ensure all the chemical is removed.

18. Guidelines for doctors asked to perform intimate body searches January 1994Revised April 1999 and November 2007

19. What is an "intimate" search? An intimate search is a search which consists of a physical examination of a person's body orifices other than the mouth.

20. Consent A fundamental ethical principle guiding medical practice is that no examination, diagnosis or treatment of a competent adult should be undertaken without the person's consent. The ethical obligation to seek consent applies even where this is not a legal requirement.

21. The doctor's ethical duty Some doctors may decide that, because of the pressures on detainees, they will not undertake intimate body searches even where the individuals give apparent consent.

22. Ironically, attempting to safeguard the patient, by refusing to comply with a consent whose validity is not beyond doubt, could, in some circumstances, be contrary to the patient's interests.

23. the individual should be informed:- that, in some limited circumstances (see below) refusal to give consent may result in the search being carried out by a police officer rather than a medical practitioner;- the health risks, if any, of refusing the search e.g. the risk of a package of drugs concealed in the rectum splitting and the drugs being absorbed into the blood stream causing an overdose;- the risks associated with the search being carried out including, where appropriate, the possibly greater risk of the search being carried out by a person who is not medically qualified;- any different procedures which may be used

24. Other options The police may, in certain specified circumstances, detain a suspect in custody for up to 96 hours by applying for warrants for further detention. Where an extended period of detention has been authorised and it is suspected that an object is concealed in the subject's rectum, or has been swallowed, unless there are compelling reasons for immediate action, a search can often be avoided by using this time to allow for the body's natural processes to either pass or dislodge the concealed object.

25. Ultrasound is the most suitable technique for non-contact searching and it can demonstrate masses of small density, for example, in the vagina but it requires the individual's co-operation. Options such as x-ray and CT scanning both involve irradiating the patient.

26. Legal provisions Various pieces of legislation … permit intimate body searches to be undertaken without the need for the subject's consent. Whilst these statutory provisions permit doctors to undertake such searches, without fear of legal recourse, they do not oblige doctors to do so.

27. Intimate searches in Scotland The Police and Criminal Evidence Act does not apply to Scotland. Where an intimate search is considered necessary in Scotland in the interests of justice and in order to obtain evidence, this may lawfully be carried out under the authority of a sheriff's warrant.