Wounds Seen in The Emergency Room

It is quite common for a pathologist at autopsy to discover gunshot wounds missed by the police at the scene or physicians in an emergency room. Emergency room physicians often miss head wounds because of long hair and back wounds because they fail to look at the patient's back. They also confuse entrances with exits. In a study of 46 cases of fatal multiple or exiting gunshot wounds by Collins and Lantz, 24 (52.2%) were misinterpreted by trauma specialists (emergency medicine, trauma surgery and neurosurgery physicians).3 The failures involved errors in interpreting the number of projectiles as well as differentiating exits and entrances. In 27 fatal cases involving a single gunshot wound, 10 cases were misinterpreted. In five (5) cases, there were errors involving misinterpretation of entrance versus exit, in one (1) the number of projectiles, and in four (4) both these errors occurred. Therefore, one must approach medical records with a degree of caution in trying to determine how many times a person has been shot as well as whether a wound is an entrance or exit. It is also quite common for a physician to fail to note in the medical records the exact location of a wound and the presence or absence of soot or powder tattooing around it. A gunshot wound may be described only as "in the right back" without any other localizing information. Occasionally, such information may be found in the nurse's notes. One must also realize that soot may have been present initially, but that the nurse who saw the patient before the physician may have wiped it off. These factors again point out the importance of retention of clothing, as the wounds in question may have been due to bullets that went through the clothing. The ambulance crews, emergency rooms, and hospitals should be instructed never to discard clothing in cases of gunshot wounds.

Surgical intervention may make interpretation of gunshot wounds difficult if not impossible as a result of the obliteration or the alteration of wounds. In gunshot wounds of the chest, the surgeon may insert a chest tube into the wound or make his thoracotomy incision through it. In gunshot wounds of the head, it is usual for the surgeon to obliterate the entrance wound in the scalp and bone when performing a craniectomy.

Some surgeons, especially those who have had military training, perform wide debridement of entrance wounds in the skin from handguns and rimfire rifles even though this is unnecessary due to the small amount of kinetic energy possessed by these bullets. As the removed tissue is supposed to be sent to Surgical Pathology for examination, this tissue can often be retrieved and examined.

Surgeons often recover a bullet that caused an injury. One should instruct them in the correct marking of such missiles. Unfortunately, it is not uncommon for a surgeon to inscribe their initials on the side of a recovered bullet rather than the nose or base, thus obliterating its rifling characteristics. In shotgun wound cases, one should also inform the surgeons that the wadding and representative pellets should be retained for evidentiary purposes.

Concealment of a wound may occur not only through the actions of a physician but also as a consequence of an unusual entrance site. At some time in every forensic pathologist's career, a case will be encountered in which the bullet enters either the nostril or open mouth, thus, presenting the pathologist with a body with no observable entrance wound. Advanced decomposition may also conceal a gunshot wound. The use of x-rays on select decomposed bodies will prevent missing such cases.

In skeletal remains, x-ray of the bones for missiles should be done routinely. It is also wise to collect the dirt underneath the skeleton and x-ray it. The author had a case in which a .22-caliber bullet was found embedded in a vertebra. Up to that time no cause of death had been determined. The entrance defect had been missed on gross examination of this bone. Subsequent x-ray of the dirt underneath the body revealed two other bullets.

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