Injury Description in the ED

Trauma means injuries. Gory open wounds that make lay-people faint. Most ED doctors are aware that a “lac is not a lac”, but the entrenched short-hand vernacular we use in ED-speak which is often technically incorrect. Whilst very few medico-legal cases actually hang on whether the open wound you treated was a true laceration or not, or on the opinion of the ED doctor, it is still important that we try to describe injuries we see using the technically correct language.  If a case you’ve seen ends up in court, your notes may be subpoenaed, but you will also have to prepare a formal written report after a request from the Police.  The more serious the case, the more likely it is that the Police will have already sought the opinion of a forensically trained doctor to see the patient, photograph the injuries, and provide an opinion as to the possible mechanisms of injury.  You are within your rights to withhold an opinion about whether the injury is “consistent with the stated cause” if you have not been formally taught how to interpret injuries, which most ED doctors haven’t.

During my ED training I was a Clinical Forensic Medicine Registrar at the Victorian Institute of Forensic Medicine (VIFM) for 6 months, and learned the correct way to describe injuries and compile medico-legal reports, and I’d strongly recommend this job for any ED trainees for your non-ED time, it was an invaulable rotation. For this article however I’m just going to show a few injury examples and their descriptions, so you can see the correct terminology.  This is from the upcoming ETM Course manual section on Specific ED Considerations – Injury Description, (Thanks to Dr Nicola Cunningham, Forensic Physician at VIFM for authoring this section).

Bruise:

bruise_1

An area of haemorrhage beneath the skin that is generally due to blunt trauma. Bruises cannot be aged on the basis of their colour, and bruises of identical age and mechanism on the body may not appear at the same time or change at the same rate. The size and shape of a bruise does not necessarily reflect the amount of force or the shape of the object responsible. Some specific bruise subtypes include imprint, fingertip, petechial and periorbital bruises.

Abrasion

abrasion_1

A disruption of the outer layers of skin from blunt trauma associated with movement. Abrasions cannot be aged. Scratches and grazes are two specific subtypes of abrasions.

Laceration

laceration_1

laceration_2

 

A full thickness wound due to blunt trauma resulting in splitting of the skin. The skin usually tears on impact where it overlies a relatively firm surface such as a bony prominence. The wound edges may be ragged, abraded, bruised, inverted. There may be tissue strands bridging the wound.

Incision/Incised Wound

incision_1

Image Source

An open wound caused by contact with a sharp object. The wound can occur in any region of the body. The edges are generally regular and clean. There is an absence of tissue bridging strands.

Describing a wound in your notes:

The following characteristics should be documented when describing an open wound in the ED notes:

  1. Site: The anatomical location
  2. Size: Approximate length, width +/- depth (if able to assess)
  3. Shape: linear, crescent shaped, stellate
  4. Orientation: vertical, horizontal, oblique
  5. Margins: regular/smooth, irregular/rough, bruised, abraded
  6. Wound type: laceration, incision, open wound
  7. Other: direction of track, involvement of deeper structures (tendons, vessels)

If you’re not sure about whether it’s a laceration or an incision – just call it an “open wound” and describe it as above in the notes.

Examples:

An example that implies blunt force:
3 x  1 cm (approx) linear, vertical laceration right lower lip, rough edges, crossing vermillion border:

An example that implies contact with a sharp object:
1 x 7 cm (approx) linear incised wound, flexor aspect mid-right forearm, smooth edges, down to, but not through deep fascia

An example that implies you’re not sure whether blunt or sharp force was applied:
2 x 5 cm (approx) open wound over left elbow, margins smooth but bruised/abraded, olecranon visible at base

Closed wounds can’t be interpreted:

Once a wound has been closed by staples, sutures, glue or steri-strips, or once healing has commenced, no comment can be made about the possible mechanism of injury. You can therefore see how accurate description prior to closure may assist a forensic physician in interpreting your notes (as they may be asked to provide an opinion on such cases).

Photographing injuries in the ED:

When forensic physicians photograph injuries to submit as evidence, certain procedures are followed so as to ensure the evidence is admissible. Firstly, written consent is obtained. Then a color card/white balance shot is taken as the first photo to allow for correct colour grading when the pictures are printed, as colour variation of a wound may be questioned in court. Secondly, the photos must be sequentially numbered with their digital file name, with no interruptions/deletions. This is to ensure that no photo has been removed (which would mean some evidence is missing).  The photos are also printed and bound into a booklet by a certified photo processing lab.  A digital photo taken on your iphone or ED camera, or taken by the patient, and emailed to the Police will most likely not be admissible as evidence in court.

Assistance with medico-legal report writing:

This subject is beyond the scope of this article, but I wanted to point out that in many states, there will be a Clinical Forensic Medicine (or similarly titled) unit attached to your capital city Coroners office, who will review medico-legal reports for free. This will ensure you won’t trip up on a technicality if you end up having to present your report in court, and I’d recommend you enlist the services of these experts if you are ever required to submit an injury-related report for a court case, to ensure that your injury descriptions are accurate.

 

One Comment on ““Injury Description in the ED”

  1. Tim Leeuwenburg

    Really useful Andy, thanks

    Been a bit of a twitter chat on this in past 24 hrs, hence the blog post. Raises other issues, some old, some perhaps new.

    The old chestnut is that of precise terminology – incisional wound vs laceration. Motor vehicle crash/collision vs accident. I think the BMJ banned ‘accidents’ a decade ago, but people still occasionally talk about them…

    The other issue is about forensic medicine. What we do matters in ED, as it MAY be challenged later in court. There was a case in the States (I think, @doconskis can correct me) where a drunk driver challenged his positive blood alcohol on basis of how the blood alcohol was taken. As doctors many of us have MINIMAL training in forensics – it may be part of the FACEM curriculum, but that doesn’t mean the junior RMO doing a BAL will know how to do, nor the isolated rural doctor or non-FACEM SMO.

    The worst example would be a forensic medical exam eg: rape. This has to be done correctly and the tautology is that those in isolated communities may not be able to access a forensic examiner due to distance/infrequency. So we ALL need to know how to conduct a proper forensic exam, test and document it – whether a simple blood alcohol, an alleged assault or a rape.

    Good post, useful

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