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Hyperhidrosis

Attack victim asks you to record injuries

Case

history

During a busy surgery John Cokor came to see the registrar. He said: 'I was attacked last night. I was not seriously injured but, as I did not go to the hospital, the police asked me whether I could see you so you could make a detailed record of my injuries.'

Dr Peter Moore discusses the implications.

Should the registrar agree and fully examine the patient?

The doctor should ask for the name of the officer involved and the crime number. By contacting the officer personally it should be possible to find out exactly what is needed.

If he wants a full forensic examination for a possible court case suggest he asks the duty police surgeon.

Forensic work is a specialist area and doctors should not get involved without any forensic training. If the case goes to court the doctor could be cross-examined and the lack of training would become obvious. This is hard on the doctor, unfair on the victim and risks a miscarriage of justice.

As GPs our role is to provide general medical services and any extra work that has been agreed such as family planning.

The phrase general medical services simply means looking after people when they are ill. A forensic examination to assess injuries is not a part of GMS. The registrar has an obligation to assess any injuries for possible treatment ­ but not for the courts.

If the examination did take place how should injuries be described medicolegally?

Great care must be taken. The reason for the examination should be written down and consent discussed and noted. Write down who told the doctor the history and whether the old notes were available.

Comment on the time and place of the examination and the general demeanour of the patient. Is he relaxed or distressed and does he look well or is he in pain?

Any injuries will need to be recorded noting the site as measured from a fixed bony point, the size, possible age and, although it is dangerous to be too precise, the type of injury.

Occasionally it is possible to suggest how the injury might have occurred and especially whether it fits the story. It is vital not to be too dogmatic. Only comment on what you can see. However horrifying the assault, remember you are only hearing and seeing one side.

Any notes must be objective and not biased in a spurious attempt to 'help' the victim.

What types of injuries are possible?

Strictly speaking an injury involves a break in the skin and so a bruise is not an injury.

·Bruise

This is a bleed under the skin. They turn yellow after about 48 hours but this can be a little as 16 hours. It is very difficult and dangerous to try to accurately date bruises. The least you can say is that it either appears recent ­ no yellowing ­ or old. The condition of the patient will affect bruising ­ young children and the elderly bruise more easily. Also remember to note whether there is a medical condition or a drug such as warfarin that would affect bruising.

·Abrasion

An abrasion is a scratch to the surface of the skin involving only the epidermis. In theory it

should not bleed as the blood vessels do not extend into the epidermis. By close examination it is possible to see in which direction an abrasion was inflicted.

·Weal

This is an area of redness from a blow that settles very quickly.

·Laceration

This is the word that most non-forensically trained doctors get wrong. A laceration is a full thickness break in the skin caused by a blunt injury. It is irregular and tissue will extend across the wound. Knives do not cause lacerations.

This is not a pedantic distinction because a criminal barrister will know the definition and, if a doctor gets it wrong, he will use it to undermine a doctor's credibility.

·Incised wound

This is a clean cut from a knife.

·Swab wound

This is an incised wound which is deeper than wide. As the skin shrinks after an injury, the wound can often appear quite small.

Key points

·It is inappropriate for the police to ask a GP to write a detailed description of injuries if the sole purpose is for legal reasons

·When describing an injury remember to mention where it took place, the time, the general demeanour of the patient and who asked for the examination

·Any wound should be measured and the site noted from a fixed bony point

·Occasionally it is possible to suggest how the injury might have occurred and whether it fits the story, but it is vital not to be too dogmatic

Peter Moore is a

GP in Torquay and

a police surgeon

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