June 21
Legal medicine (AKA forensic medicine) branch of medicine that deals with
application of knowledge to legal problems and proceedings
Pathology branch of medicine that deals with diagnosis of disease and causes
of death by means of laboratory exams of body fluids, cell samples and tissues
from the body.
-
if alive = biopsy
if dead = autopsy; systematic external and internal examination of the
dead
a subspecialty is forensic pathology: a forensic pathologist examines
persons who died suddenly, unexpectedly, violently or a medically
unattended death, an expert in determining the cause and manner of
death, involved in crime investigation, case coordinator for the medical,
forensic and scientific assessment of a given death (may be the lead
investigator), expert in interpreting the scene of death, assessing the
consistency of witnesses and interpretation of pattern injuries
SEC. 95 Code of Sanitation: Any medical officer (MHO, RHO, District Health
Officer), medical offices from law enforcement agencies, CHR and
members of the medical staff of accredited hospitals.
Medico-legal cases: deaths or injuries involving persons who have no
means of being identified, those who are pronounced dead on arrival on
ERs, deaths under the following circumstances [death occurred within 24
hours of admission, clinical cause of death is unknown, unexpected sudden
death especially when the person was of apparent good health, d/t natural
disease but associated with physical evidence of foul play, death as a
result of violence, suicide or poisoning, death d/t negligence of a 3 rd
person, including cases of child abuse, physical and sexual abuse, rape,
drug addiction and iatrogenic causes of injury, disease or death (one
caused by the medical professional such as the doctor/nurse), etc]
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Doctor as a witness:
Child Protection has set qualifications of a doctor who can provide care for the
sexually abused child and these are doctors who can also give expert testimony in
court.
1. pediatrician, gynecologist, pediatric gynecologist, family
(important that theres exposure to children)
2. formal training
3. updated with research studies
4. experience
5. regular conference, consult one another here and abroad etc
medicine
Know the value of the medical literature presented. When it comes to research
the best level of evidence is a blind test that is random.
Protect your witness. Do not allow your witness to be harassed by the other side.
If its a child witness know the rules in examination of a child witness.
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Definition of death:
The cessation of life in a previously living organism. It is a process, not a
single event.
Stages of Death:
1. Clinical or somatic death
2. Brain death
3. Biological death
4. Cellular death
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Cellular death:
Think of cells as mini tiny factories. So in cellular death, these factories shut
down one by one. And eventually, they would just break up and decay.
Cellular death itself also does not happen all at once. Cells die slowly. Because
evidence now is showing that, lets say, your skin and bones may remain what
you call metabolically active (still alive for many hours). Thats why after
death, if you need to transplant or use bones or skin, they may be harvested
and cultured up to 12 hours after the heart has ceased beating. Neurons of
course die after 3-7 minutes. The heart and kidney can still be used if theyre
harvested within 8 hours of cessation, after the person is pronounced death.
So its very important, especially when were talking about transplantation.
The person must be pronounced dead by the attending physician.
So death actually takes a long time. It doesnt mean that just because the
person stops breathing and his heart is not beating, hes dead. Its a transfer from
one state of viability to another and may be slow or rapid depending on certain
factors, like your age. The very young and the very old, they die faster. Very
young, because theyre very immature, the very old because of the wear and tear.
They dont have defenses anymore so they can die really fast. If youre very thin,
if youre malnourished, if you have all these diabetes and heart problems, your
death will be faster. Or environmental factors (good thing it doesnt snow here). If
youre sickly and its cold outside, youre not wearing anything, or youre
malnourished, youre going to die fast.
So its the physician who pronounces death when what you call the point of
irreversibility has been breached. And when is that? When does a doctor say that
the point of irreversibility has been breached?
Traditionally, when the doctor doesnt feel a pulse or doesnt hear the heart
beating and the person is no longer breathing, we say the person may have died.
1. Other ways of finding out whether that person is really dead is by putting a
mirror on the face, at the mouth and nose, of the person. If theres no
condensation on that mirror, it means the person is not breathing.
2. What we can do is also look into the eyes, through the pupils. We can see
what we call the fundus where you can see the blood vessels. If the blood
vessels are not pulsating, that means the heart is no longer beating. We
can use EEG (electroencephalogram) test. But in the province, you dont
have EEG. The doctor usually uses what you call the ophthalmoscope to
look into the eye and check if theres still pulsation. Sometimes, they dont
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Sources of organs:
Fetus contains cells which we call stem cells. They contain cells that
have the potential to become any kind of tissue, provided that tissue is
placed in the right environment. So if you put a tissue in the area of the
heart, that tissue will develop into heart cells. Anencephaly infants are
babies born with only the brain stem intact. They dont have a skull cap,
they dont have the higher brains, but just the tiny brain stem. Thats why
theyre alive, they have all those reflexes, theyre breathing except for that
abnormal head. But when they die, their hearts can be used for
transplanting to babies with congenital heart diseases.
Artificial animal transplants The problem here is, its not matching. I dont
know how compatible you can be with a pig or a cow. And the problem
there also is, that animal may have some kind of disease which the human
never gets. Whats going to happen is, its passed on to the human being
who received the disease from the pigs heart. So how are you going to
cure that illness?
We do have problems with using animal tissue, although the Philippine
Heart Center used to transplant pigs heart valves, etc. into heart valves of
patients but theyve stopped.
Homologous transplantation when tissue is removed from one part of the
body and put back into your own body. So you scrape skin from your thigh,
probably to cover a burned area in your back. Or you chip part of your
pelvis and transplant it to an area where theres a bad fracture, for that
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o
o
Cloning if you have problems, theyll just give you your clone.
July 5
When everybody dies changes can happen. How do we estimate the time of
death?
EARLY CHANGES THAT HAPPEN AFTER DEATH:
1. Rigor Mortis
2. CadavericRigidity
3. Post Mortem Hypostasis
4. Cooling of the body after death or Algor Mortis
When the heart stops and the breathing stops eventually theres a falling blood
pressure, theres no more oxygen and the cell method will stop working and
because of that your nerve cells will die and theres going to be no more
neurological activity.
When blood pressure falls down and theres no more circulation, you would
become pale. There would be pallor personae, there will be eye changes, reflex is
gone, the pupils will not dilate and will not constrict if its shown light, the blood
vessels in the fundus that you see that are actually retina. You wont see any
pulsation and if you touch the eye, its very soft. Muscles will become flaccid. As
soon as there is a loss of the muscle tone it becomes flaccid and this is termed
the primary flaccidity and this may retain any activity and may respond to other
forms of stimuli thats why you might see some twitching of the toes or some
muscle twitching thats reacting to the stimuli. Its not actually dictated by higher
senses. There will also be loss of muscle tone so your anal sphincter will just come
out. Your urinary sphincter, your urine will just come out. Or some semen might
just be emitted but that doesnt mean that he had just had sex before he died.
There will be revegitate of the gastric contents because there is a sphincter in the
esophagus and in the stomach. That will also be relaxed so when the person falls
on his back or even head down stomach opening relaxes, gastric sphincter will
flow backwards this can be confused as if the person died because of asphyxiation
(gastric contents going into the airway). The only way we can say that a person
died because of asphyxiation from aspirating food is from eyewitnesses account.
If food debris can be found down to the smallest part of the lung and then we can
say he asphyrated and that is the cause of his death.
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July 12
DEATH INVESTIGATION.. It involves police investigation and the application of
forensic science.
Kinds of death that require investigation in the Philippines, understand the
principles of death investigation including the autopsy. Learn and understand the
contents of a medico legal autopsy report and how the medico legal findings
become useful to the legal system.
The purpose of death investigation is to identify and develop an understanding of
the death of that person.
Two types of death investigation:
1. Clinical death investigation happens within the hospital. The doctor or the
medical officer or the pathologist wants to know what that person died of, what
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July 26
IDENTIFICATION OF THE LIVING AND THE DEAD
Medical reasons for establishing the identity of a living person and a dead body:
a person is comatose
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infant
for paternity and filiations for proper support, inheritance and parental
authority
You need the help of experts or forensic people like forensic pathologist,
orthodontologist, anthropologist when the dead bodies are severely injured or
severely mutilated, decomposed or skeletized.
The identity of a person is established by comparing or matching the parameters
that can be measured with the parameters of another person which is suspected
to belong to the body being measured. The best feature on how to identify a
person is his specific features that are matched to one that is known to a certain
person.
METHODS OF IDENTIFICATION:
Picture: get the frontal and the side view shot (more often than not, your
left profile is different from the right profile)
To determine the age: white thing around the eye, teeth only up to age
25 and a range is given, x-ray (oxification centers, bone growth)
Tattoos.
Other marks: Striae, pimples, cleft lip, tribal marks, body piercing.
Write down and describe all the persons individual markings and
personal characteristics
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Fingerprints
Three Types
Patent prints
Plastic prints
Latent prints
impressions
secreted
in
a
surface or an object
that is invisible to
the eye, the result
from
perspiration
from
the
sweat
pores found on the
ridges
of
sweat
pores
-invisible to the eye
-visible prints
-no
need
enhancements
for
-visible prints
no
need
enhancements
for
needs
enhancement (e.g.
dusting)
For
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Palm prints and sole prints it is believed that people do not have the
same
Ear-shape
Bite mark
Bones: sex, age only up to age 25, height, race, personal identiy:
dependent on ante-mortem data
Tissue and cell samples: blood type, protein complexes, blood enzyme
systems, etc
DNA profiling: used in exclusion and identification thru body fluids, hair
strands; DNA analysis can yield a positive identity
Principles
o
If the DNA pattern left at the scene of the crime does not match the
suspects DNA pattern, the suspect was never in that scene. If it matches
the suspects DNA pattern, it puts the suspect in the vicinity of the scene
of the crime but does not necessarily mean that he is guilty of the crime.
Ten percent of the molecule is used for genetic coding and the rest are
silent. These silent zones repeat themselves, meaning, there is only 10
percent of the billions of molecules in the body and only a few percent is
specific to you alone but the distribution is unique for each one of us, the
sequencing is different.
The DNA is found in the nucleus and it is a double helix. It is very stable
but the specimen that contains the DNA that is to be analyzed can easily
be contaminated by the collector.
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DNA fingerprinting is the last resort in identifying people. Its used for
healthcare, pharmaceutical research, evolution and forensic.
Types of samples needed for DNA analysis: it must have nucleus (white
blood cells, hair root, spermatozoa). Get a buckle smear from the side of
your mouth, vaginal swabs and anal swabs to determine presence of
semen or Y chromosome within 72 hours placed in a ref right away, blood.
Semen on clothing can stay for a year.
Half of our chromosomes come from our father and the other half from our
mother.
JULY 31 (SATURDAY)
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1. Inconclusive - DNA testing did not produce info that would include or
2.
3.
is unrelated to the suspect and chosen randomly from the population will
match the DNA profile taken from the crime scene
Likelihood ratio ratio of the probability that the DNA profile in the
evidence sample came from the suspect and the probability that the DNA
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How caused?
1. Kinetic caused by application of mechanical or physical force
Mechanical force causes two types of trauma: blunt and sharp
Blunt force trauma causes abrasions, contusions and lacerations
Sharp force trauma leads to incised wound or stab wound
Important when describing the wound how it looks like, what kind? Demand from
doctor, you have to know whether blunt or sharp force, what are the dimensions,
positions, etc.
Abrasion
-
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Lacerations
-
result of blunt force overstretching the skin and there will be a split of the
full thickness of the skin
deep and will bleed
important to look for bridging fibers (remain intact in lacerations and will
not be cut)
skin can be compressed within the applied force and the underlying bone
rare in soft fleshy areas of the body
margins are always ragged
if caused by thin sharp object, the wound is sharply defined and may be
mistaken for incision but under the microscope there could be abrasions
and contusions on the edges and bridging fibers in the laceration
1. Incised wounds
-
also caused by objects with sharp and cutting edge and distinguished from
a stabbed wound by being longer than deep
- Edges will give indication of the sharpness of the object used. Very sharp
objects will not leave bruising on the edges, no bridging fibers.
- rarely life threatening unless it cuts deep into a tissue like your jugular
artery
2. Stab wounds
-
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Mechanism of Injury
1. accident
2. self-infliction
3. action of a third party
Bite marks in a child is pathognomonic and the child was definitely abused. To
identify the teeth marks you need a dentist and you need to get an impression of
the suspects teeth and compare. It can also be a source for DNA collection.
DEFENSE WOUNDS
Found in victims who are trying to defend themselves from an attack so it will
depend on the kind of weapon used
Survival:
If theres a lot of bleeding the body has a mechanism to prevent shock called
Compensated shock. But if he will not get any medical attention and body cant
maintain it, body will go to uncompensated shock and will lead to death.
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ASPHYXIA. Absence of pulse. It describes a range of conditions for which the lack
of oxygen is considered the cause.
Mechanism: obstructive or non-obstructive
The obstructive type is medico-legally significant.
Classical Features:
It is not diagnostic. Not definite signs of asphyxia like: facial congestion, facial
edema, facial cyanosis, petechial hemorrhages in the skin and in the eye, star
dose spots
Conditions/causes
1. Suffocation
Lack of oxygen in the inspired air
Example: Putting plastic bags on the head of prisoners
There is quick death and minimal signs of asphyxia except for pallor in the
face
Not struggling to breath; there is low external pressure
2. Smothering
The victim struggles
May experience cyanosis and congestion
Bruises and abrasions on the face, on the lips, or inside the mouth
Non-struggling victims: may not see any of the signs; difficult to diagnose
3. Choking or gagging
Internal obstruction of the upper airway passages by an object or
substance impacted in the pharynx or larynx
Mucus membranes swell or congest if you breathe thru your nose
There will be respiratory distress, can become cyanosis and congested face
and neck up
4. Strangulation or hanging
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Jugular veins drain venous blood (un-oxygenated blood) from the head. If
there is obstruction, the blood will remain in the head. The person will
swell, congest or become cyanotic. The arterial veins will rupture causing
petechial hemorrhages underneath the skin.
Stimulation of the barrow nerve endings in the neck will bring about the
slowing of the heart.
External signs: abrasions and bruises in the neck area, laryngeal damage,
5. Traumatic asphyxia (restricting the movement of the chest)
External pressure is put on the chest thereby restricting respiration
Classic signs: very congested from face and neck up, person becomes very
blue or red, extensive petechia
Blood from above the chest cannot return to the heart, its just like
obstructing the jugular veins
6. Postrial asphyxia
Disabled or unconscious person lies with the upper half of the body lower
than the rest of the body
There is pressure in the abdomen that does not allow the diaphragm to
move; its like traumatic asphyxia where there is restriction of chest
movement
Commonly seen on persons arrested, they are pushed to the ground
Hemoglobin carries oxygen but it prefers carbon monoxide.
Failure of oxygen utilization will paralyze the chest muscle.
HYPOXIA. Partial lack of oxygen.
ANOXIA. Complete lack of oxygen.
Sept 13
3 GROUPS OF VICTIMS
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TRANSPORT INJURIES:
Primary injuries
60-100 km/hr victim may fly up in the air and he can fall on the car or
beyond the car.
Secondary injuries
from the contact of other objects or the ground after contact with the
vehicle
Often more serious and potentially lethal than primary injuries (e.g. head
and spinal injuries)
Car occupant
The injuries suffered will depend on the kind of impact
Motorcyle injuries
-
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Bodies recovered from water could have died from natural causes before entering
the water. Determine WON victim died of natural causes before entering the water
or while in the water having entered it either voluntarily or accidentally. Did he die
of unnatural causes before entering the water? Did he die from exposure or
hypothermia while in the water? Died of injuries after entering water? Did he die
of submersion or drowning?
Submersion just actually being in the water. A person who drowns can have
signs of being submerged but a person who was submerged in water does not
necessarily mean he drowned. If you died before you were placed in the water you
are submerged.
S/Sx of Submersion:
1.
2.
3.
4.
washerwomans fingers/hand
macerations and skin will peel off after weeks of immersion
decomposition
Eventually your body will float. The only time body wont float is when
youre submerged in very cold water.
DROWNING
-
you die of suffocation because of water within your lungs and you have to
be immersed in water
Effect depends whether you drowned in fresh or sea water. Fresh water is
absorbed into our circulatory system resulting to volume overload and
hemodilution, eventually leading to cardiac arrest.
Sea water more concentrated than blood, so fluid in our blood will go out
into our lungs and theres pulmonary edema or congestion resulting to
hypoxia, respiratory arrest, cardiac failure and cardiac arrest
Post mortem findings variable and cause of death hard to prove
5 stages
a. You struggle, you may find bruises in your chest and shoulders
b. You get tired and you sink
c. You dont want to breathe in water so you stop breathing. Because
we hold our breath carbon dioxide goes up so respiratory centers in
our body say breathe so we breathe in water
d. Cough vomit, loss of consciousness. Convulsions. Involuntary
respiratory movements and we keep inhaling water.
e. Respiratory arrest and cardiac arrest.
You could drown within 10 minutes
In 10-20% of the victims laryngospasm can happen and since larynx
remains closed water cannot enter lungs = dry drowning
The rest theres relaxation of the airway and water enters the lungs
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There can be blood tinged froth in the mouth and nostrils which is more
common in seawater drowning.
Sand, silt, seaweed may be found in the lungs sign of life before
immersion
BUT Finding of foreign material in stomach weighs heavier than finding
them in the lungs because theres a sphincter of some sort in the stomach
which does not relax when youre dead unlike airways which can relax so
water may flow freely.
ALCOHOL
Alcohol abuse usually encountered in child abuse and rape cases.
Its a drug and addictive. Makes one prone to accidents and an underlying cause
of misdemeanor, assault and homicide.
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Now the skills and the complexities as he grows older centers all in the
physical, mental, social, and emotional function of that person. It affects
cognitive development, emotional development, and social development.
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In court, lawyers should argue objections out of the childs hearing. The child
will think its his fault: My lawyer is shouting at me because I probably did
something wrong.
II. Preschool:
- May signal the start of mental and behavioral problems. The child grows
older, learns new skills, learns to be industrial, etc. If the child doesnt learn
new things, she will learn not to take any initiative at all and not develop selfesteem.
- Morally, they will do things to please the other people other than the parents.
Now they have a conscience and are aware of social norms.
- A 4-year-old victim will say, Hindi ako magsasabi kahit kanino kasi yan ang
sabi nila. Or Hindi naman ito bad kasi ginawa ni tatay. Hindi naman masakit,
nakakakiliti nga.
- A 9-year-old victim will say, Bastos tong ginagawa ko. Kung magsumbong
ako, kawawa naman si tatay, baka makulong din siya. A 4-year-old is more
inward-looking as compared with a 9-year-old.
Impact of abuse at this stage:
- Research shows that those with multiple personalities disorders and other
forms of disassociation suffered abuse prior to 8 or 9 years old.
III. Adolescence
- The offset of adolescence for girls is at 10-14, boys 13-14. Theyre now
learning how to think abstractly, but their thinking is still egocentric. They
cannot handle hypothetical situations yet.
- They now follow rules and the values of society, but they may not understand
the concept of values and rules. But here, theyre finally learning who they
are.
- Initially, it was thought that the brain develops only in the first 4 years of life,
when all the neural connections are being made. It was found that during the
adolescent stage, a lot of the neuron pathways that were hardly used got
pruned away and new pathways are being created. Another thing that they
learned was that the development of the brain is from the least complex to
the most complex, which is up in front.
- The frontal lobe, where you have what is called the neo-cortex, develops, the
area that regulates our emotions, abstract thinking, and helps us do our
executive functioning. In teenagers, this is the area thats most developed.
The frontal cortex reaches full maturity around 20 years old. Its the area for
planning, reasoning, impulse control, regulation of emotions, learning from
experiences, and weighing risks and rewards. This is the last part of the brain
that develops. Some studies have shown that this is completed at the age of
25 for males, earlier in females.
- The child has preference for physical activity.
- The person has difficulty holding back or controlling emotions. Theres still no
adequate control from the pre-frontal cortex to the amygdala. (Mood swings!
Try to remember your teenage years.)
- Studies show that, although the intellectual activity develops at 16 to 17,
psycho-socially, hes still not mature until hes 25.
- The adolescent brain is a reward-seeking brain, this is where theyre
susceptible to pear-pressure. At the age of 14, they tend to commit crimes.
- So the adolescent is actually still egocentric. They believe that they alone
have difficulties, no one else can understand or sympathize. They believe that
nothing can harm them.
Morality:
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Ability to differentiate between right and wrong and understand how to make
choices. This is discernment. Again, the childs physical, intellectual,
emotional, and mental skills, as well as his environment will influence the
development of his morality. So you have to look into his background.
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