A medico-legal view on the importance of the external examination of the traumatized patient

Abstract

Introduction. the correct registration of the external traumatic lesions is extremely important in the clinical management of the trauma, as well as in its forensic and judicial assessment. Nevertheless, the quantity and quality of the information registered in the observation charts may be suboptimal, thus significantly affecting the forensic assessment regarding the cause of death, the relationship between lesions and death, and therefore the judicial implications of the case. Material and method. We have conducted a study on a sample of 77 consecutive deaths by violence, all examined at the Institute of Legal Medicine in Iasi. A comparative analysis was conducted of the external lesions documentation in the observation chart and the forensic autopsy report, and a degree of consistency was established between the two. For each case a series of data was collected and then statistically analyzed in order to observe the existence of a correlation between the degree of accordance and of the two examinations and the registered parameters. Results. the present study has found 62.3% discordant cases. From the selected parameters, three were correlated to the degree of concordance, having the capacity to foretell whether an external lesion would be registered correctly in the observation chart: the biochemical analysis level - patients who received complete blood investigations were more frequently subject to complete skin examination in the clinic; the existence of a surgical intervention - concordance was higher in patients who suffered a surgical intervention during hospitalization; cause and context of death - patients who died as a result of burns or electrocution showed perfect concordance in 100 % of cases, while less than 3 % of patients who died in the context of aggression were recorded all types of injury. Conclusions. Better documentation of external injuries in hospital is many times essential for the medico-legal evaluation and the subsequent judicial implications. While there are factors that may explain the disregard of the registration of all traumatic marks, in the context of lack of time and the need for quick delivery of treatment, the importance of the observation sheet as a document of medico-legal and legal value must be recognized by all physicians.