EFFORTPOST Different medical cases including photos and info! pt 2

Case one:

Identification of a bomb victim.

• Identification may sometimes be challenging when the victim has severe injuries. This individual has facial injuries from a bomb explosion. Visual identification was not possible but since injury was absent to the mouth it was possible to perform a dental comparison and identify the individual. No further info.

• In cases where the remains have been badly mutilated or burned, are in advanced putrefaction, or have been submerged in water for a long period of time, the possibility of obtaining any fingerprints of value is quite remote. This is where the forensic odontologist can be of assistance. Using powerful cameras, x-rays, and medical records, he or she can, through examination of the dentition and jawbones of the deceased, provide the investigator with positive identification as well as bite-mark identification. In addition, the forensic odontologist can provide information about the deceased, including age, general facial characteristics, race, socioeconomic group, occupation, or habits.

Case two:

The patient at presentation in the emergency department, with scissors penetrating the left orbit.

• CT showing the scissors traveling to the superior aspect of the left cerebellar hemisphere. And a 3D CT reconstruction image.

• An elderly woman with schizophrenia presented with a pair of scissors penetrating her left orbit and an enucleated right globe. Computed tomography (CT) revealed a pair of scissors penetrating the superior orbital fissure, with the blades traveling lateral to the left cavernous sinus and midbrain and ending just superior to the left cerebellar hemisphere.

• She underwent left pterional craniotomy and removal of the scissors, with insertion of an external ventricular drain. Exploration under anesthesia revealed no left globe rupture, but the globe had been severed from the ophthalmic artery and nerve.

• Further patient psychiatric history revealed poor compliance with medication, leading to intense hallucinations of her deceased son’s voice telling her that her eyes were “evil” and required removal. She died 5 months later after developing an intracranial abscess.

• Autoenucleation is predominantly a manifestation of psychosis, especially if there are concurrent delusions that a patient’s eyes pose a threat to themselves or their loved ones. Initial emergency management includes CT to rule out subarachnoid hemorrhage. Antipsychotics should be considered, perhaps even in the absence of psychotic symptoms because of the near certainty of an underlying psychosis.

• Subsequent inpatient management includes one-to-one nursing, fingerless mittens, and arm restraints; these may be the only way to prevent deluded and determined patients from causing more damage as antipsychotic medications take effect. Prevention is key; mental health practitioners should be alert to delusions about eyes and consider regularly assessing a patient’s risk of self-mutilation.

Case three:

Facial injuries sustained when a letter bomb exploded as it was being opened.

• Facial injuries sustained when a letter bomb exploded as it was being opened. No further info. It is not uncommon for small explosive devices to be sent in the post to targeted individuals. The device is usually contained within a large padded envelope and detonation is usually achieved when the envelope is opened by an unsuspecting recipient. Injuries sustained in such circumstances are usually confined to the face and are often characterized by linear abrasions and lacerations radiating from a point in front of the face.

Case four:

Postmortem examination of the teeth of a badly burned body.

• Postmortem examination of the teeth of a badly burned body, in order to assist in the positive identification of the decedent. The soft tissues of the face (lips and cheeks) have been cut away in order to maximize the visibility of the teeth. Because the destruction of burned victims of the third, fourth, and fifth categories is extensive, remains cannot be identified by common methods. In these cases, forensic odontologists are called in to assist the identification by comparing the postmortem records of the burned, charred, or incinerated individual teeth with the antemortem dental clinical history.

• Dental identification is very vital tool because teeth may be the only body part that remains intact. Teeth are the hardest substance in the body and can endure extremely adverse conditions, including high temperatures up to 1600°C (2912°F). Teeth are the components of the body that often survive severe fires because of their highly resistant composition and they are protected by the soft and hard tissues of the face and other materials.

Case Four:

Complete disruption of the cranium following suicidal discharge of a shotgun in the mouth.

• Shotguns are popular world wide and more of these weapons exist than the rifled types. With an increasing incidence and prevalence of gunshot wounds it is important for traumatologists to be familiar with shotgun wound ballistics. Shotgun wounds differ from those of other missiles because the spectrum of wound severity is large owing to the fact that the pellets scatter as they travel.

• Close-range shotgun wounds can be as destructive as those from a high-velocity rifle, but longer weapon-victim ranges may produce only minimal injury. The type of shot (size and weight of pellets) used also determines the type of injury, with more serious injuries produced by the larger type of buckshot (greater than 0.14 inches in diameter). The severity of injury from birdshot depends mainly on the "effective" weapon-victim range which can be calculated from the shot size and shot pattern either clinically or from X-ray. Wounds may then be classified according to severity, yielding information on prognosis and extent of investigation and treatment required.

Case Five:

The body at the scene. Decedent lying on his right side, covered with a blue plastic bag; below the bag also the upper part of 5-L propane/butane gas bottle. Colorized by OP.

• A 30-year-old male was found fully dressed lying on his right side on his sofa in his flat. He had put a blue plastic bag over his head and upper part of the body. Close to his upper part of the body, a 5-L propane/butane gas bottle was found, the upper part of the bottle under the plastic bag. In the past, there had been severe arguments with his wife, as he had started relationships and sexual contacts with other men. However, in the basement, a rope was found at the stairway, from which it was concluded that the decedent had intended to commit suicide by hanging primarily.

• Signs of progressive decomposition, especially head and arms, were present; there were no signs of external force in the skin of the neck region. There were no signs of external violence or underlying internal disease. Propane-butane mixture, i.e. liquified petroleum gas leads to the depletion of oxygen in the air consequently causing hypoxia and anoxia, and therefore, unconsciousness and eventual death. The mechanisms of death in cases of volatile inhalation include cardiac arrhythmias, reflex cardiac vagal inhibition, and/or central nervous system depression. Similar mechanisms occur in cases of asphyxiation with a plastic bag.

Case Six:

Blunt force, sharp force, and gunshot wounds on a victim.

• The external examination is a very important part of a forensic autopsy. In some cases, particularly in homicide cases with multiple injuries, the external examination requires much more time than the internal examination. In the example shown, a case with multiple injuries, including blunt force, sharp force, and gunshot wounds, the external examination took several hours to complete. No further info.

• The post mortem external examination is the final service that a physician can render to a patient. Its purpose is not just to establish medical diagnoses, but to provide facts in the service of the judicial process and the public interest. Its main tasks are the definitive ascertainment of death, determination of the cause of death and assessment of the manner of death.

Case Seven:

Gaseous distension of scrotum and abdomen.

Did someone say "I want to see a closeup"?

• Moderately early changes of decomposition, showing gaseous distension of scrotum and abdomen, and skin slippage and blistering in dependent areas. This was after about one week since death, but the changes vary greatly with environmental temperatures.

• Usually the first external naked-eye sign of putrefaction is discoloration of the lower abdominal wall, most often in the right iliac fossa where the bacteria-laden caecum lies fairly superficially. Direct spread of organisms from the bowel into the tissues of the abdominal wall breaks down haemoglobin into sulphaemoglobin and other pigmented substances. This discoloration spreads progressively over the abdomen, which in the later phase begins to become distended with gas. At about this time, more generalized spread of bacteria begins to discolour the more moist tissues.

• The putrefactive bacteria, which largely originate in the intestines and lungs, spread most easily in fluid so they tend to colonize the venous system, haemolysing the blood that stains the vessel walls and adjacent tissues. This gives rise to ‘marbling’, a branching outline of arborescent red, then greenish pattern in the skin, seen most clearly on the thighs, sides of the abdomen, and chest and shoulders. At or even before the stage of marbling, skin blisters may appear, at first on the lower surfaces of trunk and thighs where hypostatic oedema has loaded the tissues with fluid.

• Gas formation will now become marked, with increased tension in the abdomen. The scrotum and penis may swell up to remarkable size and the neck and face will become grotesquely bloated, making visual identification difficult or impossible. The pressure may cause the eye globes and tongue to protrude. Purging of urine and faeces may occur due to the intra-abdominal pressure and, occasionally, a uterine prolapse may be extruded. There are recorded instances of pregnant women having a macabre post-mortem ‘delivery’ of the fetus, from the same cause.

Case Eight:

The man had placed the 30.06 rifle into his mouth.

The entire mouth and major portion of the victim’s skull are absent.

• Texas, USA. These photos illustrate the appearance of a crime scene indoors involving a high velocity weapon. The man had placed the 30.06 rifle into his mouth. Note that the entire mouth and major portion of the victim’s skull are absent secondary to gunshot wound through the mouth.

Case Nine:

Destruction of the head with loss of a large part of the brain after a fall from a height.

• This individual fell from a height and suffered fatal destruction of the head with a loss of a large part of the brain. No further info.

Case Ten:

Suicidal stab wound.

• Nassau County, New York - Suicidal stab wound into a female victim’s chest with the knife left in one of the wounds. Many times the medical examiner will be able to state that a wound is consistent with a particular weapon. In this case the weapon used by the victim was still in the victim.

• A stab wound is a specific form of penetrating trauma to the skin that results from a knife or a similar pointed object. While stab wounds are typically known to be caused by knives, they can also occur from a variety of implements, including broken bottles and ice picks. Most stabbings occur because of intentional violence or through self-infliction. The treatment is dependent on many different variables such as the anatomical location and the severity of the injury. Even though stab wounds are inflicted at a much greater rate than gunshot wounds, they account for less than 10% of all penetrating trauma deaths.

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