Emergency Department

emergency department
dos and don’ts

potential medicolegal cases
a. first and foremost treat the victim as indicated for any injury, whether minor or life threatening.
b. document names of who had contact with person during transportation to the emergency department (ed) document the type of medical treatment given.
c. whether the victim or, in many cases, the perpetrator presents to the ed either alive or deceased,
1. view everything as evidence or potential evidence. never throw any items away that came in with the victim or perpetrator or on the victim or perpetrator no matter how insignificant they may seem, for example,
a. chewing gum
b. clothing
c. insects on clothing
d. grasses
e. debris
f. dirt from shoes or clothing accumulated in the sheets
g. matchbook covers
h. drink containers
i. body piercing jewelry
2. document objectively not subjectively.
a. this means to document only what you see or hear or what was said. (this should be charted in quotation marks, with the specific words used, even when the language seems offensive or “off color” to you. what is stated verbally needs to be charted exactly the way it was said by victim or perpetrator.)
b. use a narrative form.
c. use drawings or diagrams to indicate where injuries are located.
d. measure the size and describe the shape and color of injuries.
e. photograph if a permit is possible to obtain.
3. document the location of injuries.
a. use a point of reference,
b. example 1: there is a 3 . 1 cm vertical laceration 12 cm distal up from the heel on the center of the left lower leg.
c. example 2: there is a 5 . 2.5 cm horizontal purple contusion
15.25 cm down from the center crown of the head on the right mandible, extending along the angle of the jaw to the center of the chin.
4. note colors and shapes of injuries.
a. this may tell which weapon was used to inflict the injury.
b. note colors of contusions and abrasions.
c. are the contusions clustered in one area?
d. example: at 4 cm down from the center anticubital area on the lower anterior surface of the left forearm, there is a cluster of multiple contusions, ranging in size from 2.5 cm to 0.5 cm. some are on top of others. they are circular in shape and range in color from reddish purple to tan.
5. look for patterned injuries:
a. bite marks
(1) are defined as a pattern made by the teeth in a medium (food, tissue, a substance that can be compressed when the pressure of biting occurs)
(2) the most important part is to recognize them.
(3) if bite marks go unrecognized, they are undocumented and become valuable “lost evidence.”
(4) bite marks can yield identification of the perpetrator and are just like fingerprints.
(5) bite marks are unique to each person or animal species.
(6) human bite marks have a circular or oval ring appearance formed by two opposing arches each point of contact leaves the size and shape of individual teeth that make up the bite mark.
(7) animal bite marks vary among breeds.
(a) generally, canine bite marks appear as a long and narrow arch.
(b) there are often deep punctures made by the “fangs” or incisors.
(c) in canine bites, drag marks across the skin are seen with lacerations, made by the dog hanging on and shaking, or are caused as the animal loses hold of the tissue as the person pulls away.
(d) claw marks can also accompany bites.
b. human bite marks.
(1) commonly occur in conjunction with
(a) domestic violence injuries
(b) child abuse
(c) elder abuse
(d) crimes of passion/torture
(e) sexual abuse
(2) on any part of the body, commonly
(a) breasts
(b) arms
(c) legs/thighs
(d) head
(e) neck
(f) genitalia
(g) buttocks
(h) abdomen
(i) face
(j) back
(3) when you see one bite, look for others.
(4) bites contain dna from the offender, so they should be swabbed, measured, photographed, and documented with the location of where they appear on the body. a forensic odontologist is able to reconstruct impressions from victims’ bite marks and match them to impressions obtained from a suspected perpetrator.
c. the weapon shape. patterns on skin should be measured, described/photographed, and documented. examples of specific weapons that leave patterns:
(1) the human hand, as in slap marks
(2) chains
(3) cords
(4) loops of cords
(5) flyswatters
(6) wooden spoons
(7) hilt of a knife
(8) boards
(9) sticks
(10) poles
(11) hammers
(12) screwdrivers
(13) soles of shoes
d. it make take several hours to days before a patterned injury appears, so check your victim daily for new bruising.
some implements leave immediate patterns this is often dependent on the location of the injury and the force applied to inflict the injury.
6. note and document any odors detected.
a. example 1: “the victim’s shirt smelled of gasoline.”
b. example 2: “when the victim arrived, there was a slight almond-like odor detected.”
c. example 3: “the odor of alcohol was detected around the victim’s mouth and nose and on his clothing.”
7. document what the victim may say (put the victim’s words in quotation marks).
a. “my wife took a knife to my arm.”
b. “he tried to kill me.”

clothing with injury marks on it, such as a shirt with evidence of a penetrating wound from a
1. stab wound
2. incised wound
3. gunshot
a. never cut through the penetration site in the clothing.
b. cut around the penetration site.

cleansing a patient who may be considered a medicolegal case

a. if possible, obtain photos prior to cleansing the victim. if photos are not possible, use a body diagram and narrative to describe what the injury/patient looks like.
b. gather evidence.
1. general. use sterile swabs to gather or collect evidence if necessary, the swab tip can be moistened with sterile water or sterile saline.
2. technique. use a rolling motion of the swab over the collection site. do not “scrub” the swab. all sides of the swab should come in contact with the area being swabbed.
3. gunshot residue. swab hands for gunshot residue law enforcement has special swabs for this.
4. blood.
5. saliva.
6. semen.
7. vomit. this may need to be collected in a container such as a sterile urine cup with a lid or a plastic suction canister, which can also be used for other body fluids.
8. label. make sure all evidence is labeled with date and time and sealed with the collector’s name and initials date and time on the tape used to make the seal.

c. if clothing is removed:
1. use paper bags to package clothing air dry wet clothing if possible.
2. keep bagged clothing in the room with you until you are able to hand it to law enforcement to maintain the chain of custody.
3. if bags are not available, put in a white sheet or wrap in white exam table paper.
4. carefully fold the sheet on which the patient was lying, taking care not to lose debris and dried body fluids that may be contained on the sheet. place this all in a paper bag.
5. document what you collected, what you did with the items, and who you gave them to. secure with available tape, label what is in the bag, indicate date and time of collection, your initials, and who it was given to.
6. never package anything in plastic bags.
a. this makes the contents airtight.
b. this allows mold and bacteria to grow, ruining any evidence.
7. always use paper or sheets they breathe and prevent overgrowth of mold and bacteria.
d. if there is a ligature around the victim’s neck,
1. take a photo or draw the ligature’s appearance.
2. never untie the ligature knot.
3. never cut through the knot itself.
4. if the patient is deceased, the ligature should remain intact on the patient until autopsy.
5. if the ligature needs to be removed,
a. never untie a ligature knot: cut it away from the victim, allowing at least 6 inches from the knot.
b. specific types of knots may give information to the investigator.
c. document which side the knot is located on the victim.
d. place the removed ligature in an evidence bag and label as discussed also document in a narrative form and use a body diagram.
e. maintain the chain of evidence
f. note skin colors seen on the victim and their location.
g. document what was used as the ligature, for example,
(1) rope
(2) nylon
(3) wire
(4) cord
6. document the appearance of the furrow on the victim’s neck (size, width, depth, and color).
e. if the patient received medical treatment via emergency medical services (ems) at the scene,
1. document names of people who came in contact with the patient.
2. indicate what kind of treatment was performed.
3. indicate who was present in the ed.
4. did ems remove any clothing? if so, where is it? what is it?

f. bag any belongings.
1. bag, label, date, time, and initial each item in a separate paper bag. this is to prevent transfer of evidence.
2. put one item of clothing in each bag, especially if blood is on clothing.
g. document in your notes the name of the officer and case number responding to the case.
h. document who you gave the evidence to, along with the date and time of each item of evidence. example: “bags 1–13 given to
officer smith on 1/11/09 at 1600” then, sign your name.


trauma: time is of the essence
a. during the times that traumas are brought into the ed, time is of the essence, and all should be considered to be medicolegal cases.
b. each case has needed evidence that should be collected.
c. lay a white sheet on a spare table or even in the corner of the room.
1. as clothing is removed, expediently it can be tossed onto the white sheet to dry and be packaged later.
2. this evidence can also be watched by one person in the room.
d. when there is time to package and label the evidence, remember to include the white sheet as evidence.
1. keep all debris that is on the sheet there (on the sheet).
a. soil
b. leaves
c. sticks
d. insects
e. any debris
2. fold the sheet and package it in a paper bag, sealing as described.

e. if insects are present,
1. collect and place them in a rubbing alcohol solution using a sterile urine container.
2. collect in a white envelope.
3. date and label as described.
4. call your local forensic entomologist for pick up or give the insects to law enforcement and document this in your narrative.
5. maintain your chain of custody.
f. if the victim is deceased and you are waiting for the medical examiner to assume custody of the body, place paper bags over each foot and hand and secure them to the victim. this prevents the evidence from being lost and provides a container for any evidence that may droping from the victim’s hands.