PENETRATING TRAUMA

Penetrating trauma occurs when an object pierces the skin and enters the body causing damage. These types of traumas are typically the result of injuries from sharp objects (like knives or broken glass) or high-energy projectiles (such as bullets).

Penetrating trauma can also be “perforating trauma”. Perforating trauma occurs when an object enters AND passes through the body creating entrance AND exit wounds. Perforating trauma is most commonly associated with ballistic wounds, which will be covered in another post; this post will focus on penetrating injuries.

The type and severity of resulting injuries depends on several factors, including:

• Location: Wounds to vital areas such as the chest, abdomen, or head can be life-threatening due to potential damage to critical organs or blood vessels.

• Depth: Shallow wounds might only affect the skin and underlying tissues, while deeper wounds can impact muscles, organs, or bones.

• Type of Object: Sharp objects tend to cause cleaner cuts, while blunt or high-energy objects can cause more extensive damage and bleeding.

• Obstacles: If an object has to go through clothing or other objects to reach the skin, the injury may be lesser in depth and severity

• Force: The stabbing force is influenced by the shape of the blade/object and stabbing velocity.  Generally, the greater the stabbing force the greater the depth and potential injury

• Victim: The underlying age and general health of the victim can influence the injury severity and healing

Common types of penetrating injuries include:

1. Knife Wounds: These cause incision (slash marks) or stab (puncture) wounds depending on how the knife is wielded. Damage can range from superficial skin injuries to deep wounds affecting muscles, blood vessels, or organs.  Sharp weapons can also strike bones resulting in a bone fracture, the knife tip could break off in the bone.  There can be a transfer of trace evidence from the knife to the bone or bone fragments onto the knife blade.

2. Puncture Wounds: Caused by sharp objects that penetrate the skin and underlying tissues, creating a small but deep wound.  They can potentially damage deeper structures like muscles, tendons, and organs, and may have a higher risk of infection.

3. Lacerations: These are tear-like wounds caused by sharp objects. Unlike clean incisions, lacerations may have irregular edges and can damage both the skin and underlying tissues. They can be superficial or deep, depending on the force and nature of the object.

4. Stab Wounds: These are a specific type of penetrating injury caused by sharp, pointed objects like knives. Stab wounds can cause severe damage depending on the depth and angle of penetration, potentially affecting internal organs, blood vessels, and other vital structures.

5. Gunshot Wounds: Often referred to as GSWs, these can cause significant damage due to the high energy of the bullet. The injury typically includes a combination of a wound channel where the bullet penetrates, as well as potential tissue damage from the bullet’s impact and fragmentation. Bullet wounds can affect bones, organs, and major blood vessels, leading to severe bleeding and trauma. Bullets or other projectiles cause these injuries. They can lead to a combination of entry and exit wounds, along with tissue damage from the bullet’s path and potential fragmentation

6. Fractures: Penetrating trauma can also result in broken bones, especially if the object causing the injury is large or if it impacts the bone directly.

7. Organs and Vessel Damage: Depending on the location and depth of the penetration, internal organs (such as the lungs, liver, spleen, or intestines) and major blood vessels can be damaged, leading to potentially life-threatening internal bleeding and organ dysfunction.

8. Infection: When the skin is broken, pathogens can be introduced into the body. These wounds can become infected if not properly treated and cleaned, leading to complications like abscesses or systemic infections.

BLUNT FORCE TRAUMA

Blunt force trauma, also known as non-penetrating trauma, occurs when the body is struck by or strikes a blunt object, leading to injury.  Although the weapon or object does not actually penetrate the skin, the skin may be broken due to the type and force of the impact. The mechanism of action involves several forces:

1. Acceleration and Deceleration: Rapid changes in speed that cause internal organs to move at different rates leading to tearing or shearing injuries.speed changes

2. Shearing: The slipping and stretching of organs and tissues in relation to each other causing significant internal damage.

3. Compression:  The body is squeezed between two objects leading to crushing injuries.

4. Torsion: Twisting forces that cause injuries to muscles, ligaments, and other soft tissues.

5. Crushing Pressure: Prolonged pressure on the body resulting in severe damage to muscles, nerves, and blood vessels.

These forces can result in a variety of injuries, including bruises, fractures, and internal bleeding. The severity of the injury often depends on several factors, such as the underlying age and health of the victim, presence of medications or other substances, and the force and location of the impact.  Some common types of injuries include:

1. Contusions (Bruises): The rupture of small blood vessels under the skin causing discoloration and swelling.

2. Abrasions: Superficial injuries where the top layer of skin is scraped off.

3. Lacerations: Deeper cuts or tears in the skin and underlying tissues.

4. Fractures: Breaks or cracks in bone due to the direct impact, shearing, compression, torsion or compression forces.

5. Internal Injuries/Bleeding: These can include damage to internal organs, such as the liver, spleen, or kidneys.

6. Traumatic Brain Injuries (TBI): These occur when the head is struck, leading to concussions or more severe brain damage.  Shockwaves from explosions can also cause TBIs.

Common signs of blunt force trauma can vary depending on the type, severity, extent, and location of the injury. Here are some typical symptoms:

1. Pain or Tenderness: This is often the first sign, occurring at the site of impact.

2. Bruising: These are common as blood vessels are damaged under the skin.  The bruising results from the leaking of blood from the damaged vessels (venules and capillaries).

3. Swelling: This occurs as a result of the increased blood/increased fluid movement to the area and the influx of white blood cells to the injured area (the body’s initial healing response injury)

4. Difficulty Breathing: This can occur if the trauma affects the chest or abdomen.

5. Nausea and/or Vomiting: These symptoms can indicate internal injuries.

6. Dizziness and/or Loss of Consciousness: This is particularly concerning and may suggest a head injury.

7. Internal Bleeding: This can be life-threatening and may not be immediately visible.

Blunt force trauma can cause death in a variety of ways which include:

• Intracranial bleeding and/or Cerebral Edema (swelling)

• Severe blood loss/Hemorrhage

• Pneumothorax (air accumulating in the space between the lung and chest wall)

• Hemothorax (blood accumulating in the space between the lung and chest wall)

• Aspiration of blood/stomach contents into the lungs

• Deep Vein Thrombosis (blood clot that forms in a deep vein)

• Pulmonary Embolism (part of a DVT that breaks off and travels to the lungs)

WHAT DO FORENSIC NURSE CONSULTANTS MEAN BY "MECHANISM OF INJURY"?

Mechanism of injury (MOI) refers to the method by which damage or trauma occurs to the body (skin, muscles, organs, and bones).  Now, this is where forensic nurses get to use those high school and freshman college physics lessons!  Understanding MOIs and the resulting bodily insults requires combining a bit of physics with anatomy and physiology to determine the effect of the manner (type), direction, amount, and location of force applied to the body and the resulting injury/injuries.

Isaac Newton’s First Law of Motion states that a moving object will continue to move at the same speed until an opposing or outside force acts upon it.  When this happens, the object’s kinetic energy is transferred to the outside object. For our purposes, the object is a weapon of some type, and the outside object is the body and this transfer of energy causes trauma or injury (typically, blunt/non-penetrating or penetrating). However, the transfer of energy can also be through a thermal agent such as heat, chemical, or cold agents and can also cause trauma to the body. This concept of the transfer of energy helps healthcare providers assess the likelihood and severity of injuries based on the nature of the incident and the Forensic Nurse Consultant to link (or not) the injuries to the indicted charges.

In forensics, determining the mechanism of injury (MOI) is crucial for understanding how an injury occurred, which can help in criminal investigations and legal proceedings. Forensic experts analyze the physical forces and mechanical processes that caused the injury to determine the nature of the incident (i.e. accidental, self-inflicted, self-defense, or an intentional violent act).  For example, in cases of blunt force trauma, the MOI can help differentiate between injuries caused by falls, car accidents, or assaults. Similarly, in cases involving sharp force injuries, understanding the MOI can reveal whether the wounds were caused by knives, glass, or other sharp objects and the directionality and/or angle of entry.

More specifically, when evaluating a case, Forensic Nurse Consultants consider the following:

1. The nature of force applied to the body

2. The estimated amount of force applied to the body

3. The events leading up to the transfer of energy/trauma

4. Positioning, location, and movement of the assailant and victim

5. Physical capabilities of the assailant

6. General medical condition of the victim

7. Post-injury medical care (when and what) provided to the victim

MOI can be crucial in determining court cases for several reasons:

1. Establishing Liability

2. Supporting Evidence

3. Refuting or Confirming Defenses

4. Accurate Diagnosis and Treatment

MOIs are broadly sorted into several categories, based on the type and amount of energy transferred. Each has distinct characteristics and associated injuries.

1. Blunt

2. Penetrating

3. Ballistic

4. Acceleration/Deceleration

5. Thermal

6. Chemical

7. Electrical

8. Blast

9. Crush

10. Asphyxial

HOW FORENSIC NURSE CONSULTANTS EVALUATE VIDEO FOOTAGE IN CRIMINAL CASES!

Forensic nurses play a crucial role in assisting law enforcement with evidence collection and attorneys with analysis of this evidence. Part of this in-depth review includes reviewing video footage.  They will often be provided with video footage such as:
🎥 Body-Worn Camera Footage
🎥 Surveillance Cameras
🎥 Dash Camera
🎥 Security Systems
🎥 Interview Room Cameras
🎥 Personal video from victim, witness, or perpetrator

When forensic nurses review video footage, they focus on several key aspects:
👀 Injuries and Trauma:
They look for signs of physical injuries, such as cuts, bruises, or gunshot wounds. They also watch for the individual's movement, range of motion and for any signs of pain. Assessing the severity and location of injuries helps determine the force used and the potential impact on the victim’s current and future health.

👀 Behavioral Observations:
Forensic nurses pay attention to the behavior of both victims and suspects.
They note any signs of distress, fear, or aggression, which can provide valuable context. If a victim/suspect is known or suspected to be under the influence of drug or alcoholic substances, the forensic nurse can observe their behavior to corroborate or refute these assertions.

👀 Evidence of Assault or Abuse:
They examine the footage for any actions that indicate non-consensual behavior. Detecting signs of sexual assault, domestic violence, or other forms of abuse is crucial.

👀 Timelines and Sequences:
Forensic nurses verify the sequence of events. They correlate actions captured on camera with victim statements and other evidence.
They are also able to determine the injury progression through the videos if multiple videos were taken over a period of time.

👀 Medical Interventions:
If medical interventions occur during the footage (e.g., CPR, wound care), forensic nurses assess their appropriateness and effectiveness.

👀 Crime Scene:
Look at the crime scene to determine if there are elements that may have impacted the injuries sustained or explain the lack or absence of injury.
Reviewing police camera footage enables the forensic nurse consultant to obtain a “real-time” view of the incident aftermath and to obtain information with context that is lost with written/document evidence and photographs.  Helps them provide expert insight.

How can Forensic Nurse Consultants impact criminal charges?

🔎 Mitigating Factors:
Forensic nurse consultants identify mitigating factors related to the injuries. They examine all available documentation to understand the case background and context of the injuries. They also review all medical records of the alleged victim and/or perpetrator for medical conditions or medications that may have contributed to the injuries.

🔎 Severity Assessment:
The severity of the injury needs to meet the definition of the charges.  By accurately determining injury severity, forensic nurses can provide expert input as to whether charges could be upgraded or downgraded.
❓ Are the injuries consistent with the explanation?
❓ Are there alternative explanations?
❓ Do the injuries look chronic or recent?
❓ Are there injury patterns that may indicate the type of object used?
❓ Do the medical records provide clear timeline of the medical history?
❓ Were there treatments, previous injuries, or follow-up appointments?
❓ Are there inconsistencies that could indicate underlying issues?
❗ They consider factors like healing time, pain level, and long-term consequences such as disfigurement, scarring, physical limitations, loss of function, and/or risk of death.
📸 They interpret photographs of injuries taken at different stages (immediately after the incident and during healing) and document the extent and progression of injuries visually. The absence of photographic evidence of injuries significantly hinders injury evaluation and analysis

🔎 Expert Testimony:
Forensic nurses can testify in court as expert witnesses. The objective of their testimony is to educate the judge and jury on the medical evidence and issues in order for an informed decision to be made. Their objective analysis can support a defense argument for reduced charges or the prosecution argument for greater charges.

🔎 Collaboration with Legal Teams:
Forensic nurses work closely with attorneys, providing insights into the medical aspects of the case. They collaborate with legal teams to build a stronger defense or prosecution litigation strategy and/or negotiate plea deals.

⭐ Forensic nurses DO NOT directly change the charges but contribute valuable information to the legal process.

Distinguishing the TYPE of wound present and its specific characteristics

Forensic Nurse Consultants see many types of injuries when they are evaluating cases. It is important to know the specific type of injury when reviewing cases.

Some of the more common types of wounds are:

🔴 Incision: Clean, straight cuts typically caused by sharp objects where length is usually greater than depth

🔴 Laceration: Irregular tear-like wounds caused by blunt force or trauma

🔴 Abrasion: Superficial wounds resulting from friction or rubbing of the skin’s surface

🔴 Puncture: Small but deep wounds typically caused by sharp, pointed objects where depth is usually greater than length

🔴 Contusion (AKA bruise): When small blood vessels are torn and leak blood under the skin

🔴 Thermal, chemical, or electrical burns: Skin tissue damage caused by heat, chemicals, electricity, etc.

🔴 Penetrating wounds: Injuries that extend into internal organs or body cavities

🔴 Skin ulcers: A type of chronic sore where the skin layers “break down”

🔴 Avulsion: When a body part is torn off by trauma

🔴 Hematoma: A collection of blood that forms outside of the blood vessels

🔴 Fracture: A break or crack in the bone

It is ESSENTIAL to document the specific identifying characteristics of each wound including:

🔷 Location: The wound’s position on the body can provide insights into the assault or criminal acts

🔷 Pattern and Shape: The wound’s shape, edges, and any visible patterns can help identify potential weapons or objects involved

🔷 Depth: The wound's depth can help assess the weapon, the assailant/size of the suspect, etc.

🔷 Contamination: Detecting foreign materials (e.g., dirt, debris, or clothing fibers) within the wound can provide clues about the circumstances, location, etc. of the crime

🔷 Bruising: Forensic nurses look for bruising to understand the force applied during the injury

🔷 Healing Stage: Evaluating the "freshness" of the wound can help determine when the wound occurred

❗ Photographic Documentation is ESSENTIAL to accurately record the wound and can be used in legal proceedings

Forensic nurses collaborate with law enforcement, attorneys, and other professionals to build a comprehensive picture of the injury. 🕵️‍♀️🔍

FORENSIC NURSE CONSULTANT AND CASE EVALUATION

Another crucial role of FNEs in case evaluation is analyzing medical records and other pertinent documentation. Discrepancies, inconsistencies, injuries, timeline gaps, documentation, or explanations of events, can hinder the FNE’s analysis and expert opinion and warrant further investigation.

Initial Case Assessment:

FNE LNC's review medical records, forensic reports, police reports, statements, interviews, indictments, Grand Jury testimony, etc. to get case details as to what the prosecution aims to prove, and the defense may try to dispute or mitigate.

Medical Records Examination:

They review medical records looking for discrepancies between the patient’s account and the documented injuries. This also allows for the identification of issues such as pre-existing conditions, medications, or deviations from the standards of care that may have impacted or contributed to the injuries sustained, and incomplete or vague documentation that does not provide a clear medical picture of the patient or injuries. They may also need to evaluate the suspect's medical records to identify mitigating factors to assist in explaining their behavior or to dispute their capabilities to perform certain criminal actions.

Injury Descriptions - Correlation with Explanation:

Forensic nurses compare the documented medical findings and injuries with the patient’s explanation paying close attention to details such as location, size, shape, and characteristics of each injury. 3 key elements are:

1. Timing: Do the reported time and nature of the injury align with the medical evidence?

2. Mechanism of Injury: Do the injuries match the described cause (e.g., a fall, assault, self-defense or accident)?

3. Patterns of Injury: Are the injury patterns typical of the stated cause, or do they suggest a different mechanism (e.g., defensive wounds vs. accidental cuts)?

Timeline and Chronology:

They utilize available records, medical and others, to establish a timeline of events based on records and determine if the injuries correlate with the described sequence of events.

KEY WAYS THAT FORENSIC NURSE CONSULTANTS EVALUATE CRIMINAL CASES

An FNE’s comprehensive understanding of the mechanisms of injury and the resulting insult to the human body significantly enhances their ability to evaluate criminal cases and provide insights into the nature and potential causes of injuries.

The key ways FNEs do this are:

• Accurate Injury Assessment: assessing and documenting the nature, extent, and patterns of injuries and distinguishing between different types of trauma, such as blunt force, sharp force, or ballistic injuries.

• Determining Cause of Injuries: inferring the potential causes of injuries, determining whether injuries are accidental, self-inflicted, or inflicted by another, and establishing the mechanism of injury.

• Correlating Injuries with Evidence: reconstructing the events leading to the injury and correlating physical injuries with other evidence, such as bloodstain patterns, weapon characteristics, and environmental factors.

• Identifying Signs of Abuse or Neglect: signs can be subtle and may be easily missed by those without specialized training.

• Collaborative Investigations: working with other professionals to guide investigations, support the development of case theories, and assist in formulating questions for witnesses and suspects.

• Evaluation of Consistency: determining if the victim’s and/or suspect’s accounts of events correlate with the physical evidence and/or medical findings.

By leveraging their knowledge of trauma, forensic nurse consultants play a vital role in uncovering the truth in criminal cases and providing a thorough and scientifically sound evaluation of injuries.