Good medical practice obligates health care providers in the
ED to serve as an interface between patients and the state within
the context of the public health, legal, and justice systems. To
comply with these additional responsibilities, clinicians must be aware
of local public health and legal obligations and must be able to
recognize patterns of injury. Document observations appropriately
and process evidence in a manner consistent with legal standards.1
Local and public health responsibilities also include the recognition
of potential epidemics or bioterrorist events. ED patients fall
under medical examiner jurisdiction if they die suddenly and unexpectedly
without a clear diagnosis. Examples of surveillance originating
in an ED include West Nile encephalitis in New York2 and
the anthrax deaths in 2001.3 Any death that results
from the deliberate dissemination of an otherwise natural disease
is also a homicide and must be reported to the medical examiner
or coroner. Other examples of unexplained deaths include the series
of cyanide-laced acetaminophen deaths.
Each ED should provide its physicians with a standard protocol for
responding to state-imposed legal and public health requirements. As
an example, all states impose an obligation to report certain infectious
diseases,4 and many states also require reporting
of certain injuries to state social services or law enforcement agencies.
Generally, these reporting requirements are centered on vulnerable
patients such as children,5 the elderly, and victims
of domestic violence. Reporting laws for other types of injuries
vary from state to state. There may be obligations to report gunshot
wounds, knife wounds, assaults, and burns.
When evaluating a patient with injuries that have potential forensic
implications, take a proper history from the patient and other reporting
witnesses, and include information about the origin of the injury.
Document the statements verbatim, if possible, in case contradictions
arise later on, and because such statements are of legal significance
and are admissible in subsequent legal proceedings.
Examine the injury and document the state of the injury
before the injury is altered by healing or medical treatment. Other
diagnostic and documentary tools, such as photographs and radiographs,
should supplement the physical examination.
Injuries may be classified in a variety of ways: mode of production,
circumstances of infliction, or by injury pattern. Mode
of production includes blunt force, sharp force, missile, heat,
electricity, and chemicals. Circumstances of infliction are accidental,
suicidal, or homicidal. Wounds may be characterized as surgical
or ritual, depending on the setting in which these wounds are sustained.
The most useful classification is based on the components of the
injury pattern. Injuries consist of one or a combination of several
types of tissue damage (Table 263.2-1).
Table 263.2-1 Types of Tissue
Damage from Injury