Burned bodies: post-mortem computed tomography, an essential tool for modern forensic medicine

Abstract

Currently, post-mortem computed tomography (PMCT) has become an accessible and contemporary tool for forensic investigations. In the case of burn victims, it provides specific semiologies requiring a prudent understanding to differentiate between the normal post-mortem changes from heat-related changes. The aim of this pictorial essay is to provide to the radiologist the keys to establish complete and focused reports in cases of PMCT of burn victims. Thus, the radiologist must discern all the contextual divergences with the forensic history, and must be able to report all the relevant elements to answer to the forensic pathologist the following questions: Are there tomographic features that could help to identify the victim? Is there evidence of remains of biological fluids in liquid form available for toxicological analysis and DNA sampling? Is there another obvious cause of death than heat-related lesions, especially metallic foreign bodies of ballistic origin? Finally, what are the characteristic burn-related injuries seen on the corpse that should be sought during the autopsy?

Teaching points

• CT is highly useful to find features permitting the identification of a severely burned body.

• PMCT is a major asset in gunshot injuries to depict ballistic foreign bodies in the burned cadavers.

• CT is able to recognise accessible blood for tests versus heat clot (air-crescent sign).

• Heat-related fractures are easily differentiated from traumatic fractures.

• Epidural collections with a subdural appearance are typical heat-related head lesions.

Proof of patient information: Analysis of 201 judicial decisions

INTRODUCTION

The ruling by the French Court of Cassation dated February 25, 1997 obliged doctors to provide proof of the information given to patients, reversing more than half a century of case law. In October 1997, it was specified that such evidence could be provided by "all means", including presumption. No hierarchy in respect of means of proof has been defined by case law or legislation. The present study analyzed judicial decisions with a view to determining the means of proof liable to carry the most weight in a suit for failure to provide due patient information.

MATERIAL AND METHOD

A retrospective qualitative study was conducted for the period from January 2010 to December 2015, by a search on the LexisNexis^® JurisClasseur website. Two hundred and one judicial decisions relating to failure to provide due patient information were selected and analyzed to study the characteristics of the practitioners involved, the content of the information at issue and the means of proof provided. The resulting cohort of practitioners was compared with the medical demographic atlas of the French Order of Medicine, considered as exhaustive.

RESULTS

Two hundred and one practitioners were investigated for failure to provide information: 45 medical practitioners (22±3%), and 156 surgeons (78±3%) including 45 orthopedic surgeons (29±3.6% of surgeons). Hundred and ninety-three were private sector (96±1.3%) and 8 public sector (4±1.3%). Hundred and one surgeons (65±3.8% of surgeons), and 26 medical practitioners (58±7.4%) were convicted. Twenty-five of the 45 orthopedic surgeons were convicted (55±7.5%). There was no significant difference in conviction rates between surgeons and medical practitioners: odds ratio, 1.339916; 95% CI [0.6393982; 2.7753764] (Chi² test: p=0.49). Ninety-two practitioners based their defense on a single means of proof, and 74 of these were convicted (80±4.2%). Forty practitioners based their defense on several means of proof, and 16 of these were convicted (40±7.8%). There was a significant difference in conviction rate according to reliance on single or multiple evidence of delivery of information: odds ratio, 0.165; 95% CI [0.07; 0.4] (Chi² test: p=1.1×10^-5).

DISCUSSION

This study shows that surgeons, and orthopedic surgeons in particular, are more at risk of being investigated for failure to provide due patient information (D=-0.65 [-0.7; -0.6]). They are not, however, more at risk of conviction (p=0.49). Being in private practice also appeared to be a risk factor for conviction of failure to provide due information. Offering several rather than a single means of proof of delivery of information significantly reduces the risk of conviction (p=1.1×10^-5).

LEVEL OF EVIDENCE

Level IV: Retrospective study.

Relationships between age and microarchitectural descriptors of iliac trabecular bone determined by microCT

AIM

Estimation of age at death is a major issue in anthropology. The main anthropological histological methods propose studying the architecture of cortical bone. In bone histomorphometry, researches on metabolic bone diseases have provided normative tables for trabecular bone volume (BV/TV) according to age and gender of individuals on trans-iliac bone biopsies. We have used microCT, a non-destructive tool for measuring bone volume and trabecular descriptors to compare the French tables to a series of forensic anthropological population and if the two iliac bones could be used interchangeably.

METHODOLOGY

Coxal bone of a personal forensic collection whose age and gender were known (DNA identification) were used. Bone samples, centered on the same area than bone biopsy. MicroCT (pixel size: 36μm) was used to measure BV/TV and morphometric trabecular parameters of microarchitecture. An adjusted Z-score was calculated for BV/TV to compare with normative tables and a right/left comparison of trabecular parameters was provided.

RESULTS

Twenty-seven iliac bones, which 20 forming 10 complete pelvises, aged between 24 and 73y.o. (average of 47.7 y.o.) were used. All adjusted Z-score were within normal values. There was a strong positive correlation between right and left sides for Tb.Th, Tb.N and Tb.Sp, but an insignificant correlation was obtained for BV/TV.

CONCLUSION

Normative tables between age and BV/TV are valid and therefore usable in anthropology. They may represent an alternative to determine the age at death. Nevertheless, it requires a precise technique that could be a drawback in current practice.

The problem with medical research on tissue and organ samples taken in connection with forensic autopsies in France

Currently, in France, it is legally impossible to conduct scientific research on tissue and organ samples taken from forensic autopsies. In fact, the law schedules the destruction of such samples at the end of the judicial investigation, and the common law rules governing cadaver research cannot be applied to the forensic context. However, nothing seems in itself to stand in the way of such research since, despite their specific nature, these samples from forensic autopsies could be subject, following legislative amendments, to common law relating to medical research on samples taken from deceased persons. But an essential legislative amendment, firstly to allow the Biomedicine Agency to become authorized to issue a research permit and secondly, to change the research conditions in terms of the non-opposition of the deceased to said research. Such an amendment would be a true breakthrough because it would allow teams to continue to move forward calmly in research, and allow this research to be placed within a legal framework, which would promote international exchanges.

DES daughters in France: experts' points of view on the various genital, uterine and obstetric pathologies, and in utero DES exposure

BACKGROUND

Compensation of diethylstilbestrol exposure depends on the judicial system. In France, girls having been exposed to diethylstilbestrol are currently being compensated, and each exposure victim is being evaluated. Fifty-nine expert evaluations were studied to determine the causal relation between exposure to diethylstilbestrol and the pathologies attributable to diethylstilbestrol.

METHODS

The following were taken into consideration: age at the first signs of the pathology; age of the sufferer at the time of evaluation; the pathologies grouped into five categories: fertility disorders - cancers - mishaps during pregnancy - psychosomatic complaints - pathologies of "3rd generation DES victims"; submission of proof of DES exposure; the degree of causality determined (direct, indirect, ruled out).

RESULTS

61% of the cases related to fertility disorders, 28.8% to cancer pathologies (clear-cell adenocarcinoma), 18.6% to mishaps during pregnancy, 8.5% to disorders resulting from preterm delivery, and 3.4% to psychosomatic disorders. Some cases involved a combination of two types of complaints. Indirect causality was determined in 47.1% of the cases involving primary sterility, in 66.7% involving secondary sterility, and in 5 out of 6 cases of total sterility. There is direct causality between in utero diethylstilbestrol exposure and vaginal or cervical clear cell adenocarcinoma. Causality is indirect in the case of disorders linked to prematurity in third generation victims.

CONCLUSION

Causality was determined by the experts on the basis of scientific criteria which attribute the presenting pathologies to diethylstilbestrol exposure. When other risk factors come into play, or when exposure is indirect (third generation), this causality is diminished.

Bone microarchitecture in males with corticosteroid-induced osteoporosis

SUMMARY

Microarchitectural changes in trabecular bone were analyzed by microcomputed tomography (microCT) and histomorphometry in 24 patients with corticosteroid-induced osteoporosis. The microCT images revealed a reduction in trabecular thickness only on frequency distribution curves, with no increase in trabecular separation. Trabecular plate thinning and perforations were easily identified.

INTRODUCTION

Corticosteroid-induced osteoporosis (CSIOP) is mediated by direct actions of the drug on bone cells. The result is a decrease in trabecular bone mass and a reduction in trabecular thickness, but connectivity is believed to remain rather well preserved.

METHODS

Twenty-four transiliac bone biopsies from patients with CSIOP were studied conjointly by histomorphometry [with two-dimensional (2D) architectural descriptors] and microCT (with 3D analysis of trabecular characteristics, including trabecular thickness and separation). The frequency distribution of thickness and separation were compared with data obtained in nine control subjects.

RESULTS

2D histomorphometry revealed a decrease in bone volume and trabecular thickness in the bone biopsies of the CSIOP patients when compared to those of the controls. MicroCT appeared to be able to identify the reduction in thickness only when the frequency distribution of trabecular thickness was computed. No difference for the curves of the frequency distribution of trabecular separation was evidenced between patients and controls. MicroCT and 2D histomorphometric results were correlated, but 2D analysis appeared to be more sensitive. However, microCT identified a very specific thinning of the trabecular plates in their center that corresponds to the earlier stages of perforations.

CONCLUSION

Trabecular plate thinning can be observed and perforations occur on very thin plates in CSIOP patients.

Healthcare law in France: towards healthcare emancipation for minors

In France, since 1974 the rights of minors have been gaining ground. The first provisions to this end concerned medical acts in relation to the minor's sexuality (contraceptives and pregnancy termination). The law dated March 4, 2002, relating to patients' rights, gave more scope to this movement, by widening minors' rights so that they could demand confidentiality with regard to their parents. The minor's exercising of these rights can pose a lot of problems. In French law, parental authority is the main representation of the minor. The medical doctor treating a minor must obtain parental authorization. However, the public healthcare code provides that the doctor can override parental wishes during some situations (emergency; parents refuse). But these situations are exceptional. Since 2002, the legislator has gone further, by allowing the doctor to grant requests for care by the minor without parental authorization. However, parental authority remains the normal framework for the protection of a minor. The doctor will have to judge the reasoning and motives of a minor requesting confidentiality regarding their parents in order to decide whether he should grant or refuse care in such conditions.

[More on compensation of the handicapped child]

By adopting a heading enTITREd "solidarity towards handicapped people" within the French law dated March 4, 2002 on health reform, the government hoped to put an end to the controversy that ensued after the so-called "Perruche" ruling. Since then, several rulings have been given by administrative jurisdictions and it seems that debate in this area is far from over. The first point developed concerns issues raised about the concept of 'characterized malpractice' introduced under this law, the only type of malpractice that may render a doctor liable. A ruling by the Council of State on February 19, 2003 and two decisions by the Administrative Appeal Courts dated February 19 and April 20, 2004 gave an answer. Recent decisions, namely a ruling by the Council of State dated February 9, 2005, seem to confirm this impression. Characterized malpractice that can render a doctor liable is not gross neglect but rather neglect that is simple, certain and cannot be contested. However, due to its intensity and its proof, this type of neglect is more than just ordinary negligence. The second point discussed is the limitation of parents' compensable hardship attributable to medical malpractice. The law dated March 4, 2002 limited this compensation "solely to parents' hardship" to the exclusion of expenses incurred as a result of the child's handicap. National solidarity, which was intended to absorb this expense, is taking some time to become apparent. The legal decisions given since 2002 have thus brought about a certain level of unease both in public opinion and the legal profession. In June 2003, the Parisian Court of Appeal gave a surprising but apt ruling that may nevertheless bring certain concerns to the surface. To our knowledge, the Council of State has yet to issue an opinion on this subject. Doctors' liability in terms of the birth of child born with a congenital handicap is still a possibility.

Refus de soins du patient, le problème épineux des témoins de Jéhovah

The principle of respecting the patient's wishes is an international medical principle, found in several texts. In France, it was recalled in the 1994 Civil Code concerning bioethical laws and has recently been included in the Public health Code (law concerning patient's rights dated March 4, 2002). According to these various texts, the patient's wishes must always be respected, even in life threatening cases, so long as the patient has been informed of the risk. The refusal by Jehovah's witnesses to receive blood transfusion is always a problem. When, in full consciousness, a patient refuses a blood transfusion that his life depends on, what should the physician do? In June 1998, the Paris Court of Appeal ruled on this case. The judges found that "the obligation of the physician to always respect the wishes of the patient.is limited by the other obligation of the physician (the basis of a physician's activity) which is to protect the health and life of that same patient". In October 2001, the State Council ruling on this particular case found that, given the critical conditions of this case and the absence of a therapeutic alternative, the physicians had not committed an error. But it was also clearly underlined that a physician must respect the wishes of the patient and that this obligation must not be superseded by the duty of saving a life, thus disputing the judges of the Court of Appeal. Two questions. Two emergency interim rulings confirmed the position of the judges: the non-respect of the patient's wishes is an infringement of individual freedom. It is only in extreme and clearly defined circumstances that the physician will not be punished for this offence. This raises two questions: can a physician treat a patient against his/her wishes? And what risks does the physician take when respecting the patient's wishes when his/her life is at stake?

Patients refusing medical attention: the case of Jehovah's Witnesses in France

Respect for the wishes of a patient is internationally accepted as standard medical practice. In French law, this principle is enshrined in the Civil Code of 1994 which concerns bioethics. More recently in 2002, we find it included in the Code of Public Health (in the law concerning patient's rights). According to these texts, the patient's wishes must always be respected even when his life is at stake, so long as the patient has been informed of the risk. The refusal by Jehovah's witnesses to receive blood transfusion always poses a problem. When, in full consciousness, a patient refuses a blood transfusion his life depends on, what should the doctor do? In June 1998, the Paris Administrative Court of Appeals ruled on such a case. The judges found that. In October 2001, the State Council decided in this particular case, that given the critical situation and the absence of a therapeutic alternative, the doctor had not committed an error. But it also clearly reiterated that the doctor is required to respect the wishes of the patient and that this obligation does not override the duty of saving a life. Two emergency interim rulings by the Lille Administration Court (25th August, 2002,) and by the State Council (6th August, 2002) confirm the position of the judges. Not respecting the patient's wishes is a great infringement of individual freedom. The doctor will not err only under extreme and precise conditions. Should the doctor go against those wishes? Should the wishes of the patient be respected when their life is at stake? The authors will discuss these two questions.

[Chemical submission]

INTRODUCTION

The clinical submission syndrome is well known by the general population, but too frequently ignored by physicians.

OBSERVATION

A 23 year-old woman was drugged by a third person wishing to sexually abuse of her. The diagnosis was proved biologically after the judicial enquiry.

COMMENTS

The diagnosis of clinical submission is difficult to make because of the frequent delays in emergency consultations and the difficulties in biological assays, since the doses of drugs administered are often very low and infra-therapeutic. Over a period of one year, we evoked the diagnosis four times and it was confirmed only once. It sometimes leads to diagnostic peregrinations. Close cooperation between the physicians and the police is required so that a judicial enquiry can be rapidly set-up.

Fatal blunt pancreatic trauma secondary to assault and battery: a case report

The authors report on an fatal case of closed trauma of the pancreas in a context of violence. A 55-year-old man was found unconscious on the sidewalk and died a short time after being taken to the hospital. He had been hit with several punches to the face and abdomen 6 h before. The post-mortem examination showed numerous bruises over the whole body, a haemoperitoneum, a fissuration of the spleen and a massive peripancreatic haemorrhage associated with a complete dilaceration of the pancreas head. Histological examination of the pancreas revealed a massive necrosis associated with a subtotal disappearance of the acini, numerous sites of cytosteatonecrosis and a large haemorrhagic suffusion of the peripancreatic tissue. This case illustrates the possibilities of pancreatic injuries induced by blunt force aimed at the abdomen in a context of violence. Even if this occurs as an isolated injury it can result in rapid death because of the particular type of pancreatic fracture which is frequently involved. In postmortem situations, the pancreas should be systematically checked at necropsy and a histological examination should be carried out at the slightest doubt of a pancreatic lesion or suspicion of blunt force abdominal injuries.

[The obligation of means and the obligation of results]

Several important decisions were made in 2000 concerning the proof of malpractice and the fundamental principles of medical responsibility. In order to guarantee indemnities for victims of medical accidents, the French courts have facilitated the implication of medical responsibility for medical accidents. The notion of a "virtual fault" was developed allowing the courts to retain the responsibility of the surgeon for instance for injury to the sublingual nerve during extraction of a wisdom tooth or for injury to the popliteal artery (March 23, 2000). These decisions not only facilitate the demonstration of malpractice but also modify the definition of responsibility, all physicians being required to use all available means. Likewise, although jurisprudence asserts that a safe result is mandatory in certain areas, the essential obligation is the absence of "fault" and not the result despite the disquieting arguments put forward by the Paris appeals court in its January 15, 1999 decree. The patient's right to a result was sustained only in well defined areas.

[Medical civil responsibility in the year 2000]

In France, during the last year, important jurisprudence was established by the French Supreme Court of Appeal concerning the physician's civil responsibility. On october 7, 1998, the Court decided that "the physician is not exempted for the obligation to provide information by the simple fact that these risks only materialize exceptionally". This means that from now, the physician must inform the patient of all risks that might influence the patient's decision, particularly information concerning life-threatening or severe consequences, but also, as in the past, concerning frequent even benign consequences. The limits of this jurisprudence and the completeness of the information, as established in 1998, are emergency, patient refusal and impossibility to inform the patient. In the decree of May 23, 2000, the Court gave its definition of impossibility to inform the patient, thus establishing the "therapeutic limits". But the judges recognized that the requirement for information delivery is independent of the necessary or unnecessary nature of the therapeutic act. However, in the decree of June 20, 2000, the Court established the conditions for awarding indemnities for defective information delivery. Defective information delivery is not sufficient in itself to constitute a civil offense. Real damage is also necessary. To be awarded with an indemnity, the patient must prove that the lack of information affected his/her decision to consent. If it appears that even if he/she had been well informed, the patient had consented to the care given, the physician would not be obliged to provide the patient with an indemnity. The judges want to find a compensation and make the proof easier for the patient. They accept the potential fault when an organ was injured in the course of an operation. But, these decisions concern the proof and they don't modify the medical responsibility. The physicians have got a duty to use reasonable skill and care and they don't have any obligation to achieve a certain result. Sometimes, the physician has got an obligation to achieve a certain result but it isn't a general rule (November 08, 2000).

[Intra-familial graft. Respecting public health regulation and professional confidentiality may be incompatible]

Under specific conditions, French law authorizes organ donation despite the donor's seropositivity for certain infectious conditions. The recipient must however be informed of the potential risk of graft-related infection. Anonymous donation being the rule, the rights of the donor are respected since his/her serological status remains a medical secret. However, an exception to the rule of anonymous donation is allowed for organ donation between family members. In such a situation--often justified by the urgent nature of the transplantation--the donor's serological status would have to be revealed to the recipient, breaking the rule of medical secrecy. The physician who breaks the rule is simply implementing legal regulations (with the subsequent protection against any penal or disciplinary measures) but nevertheless performs an ethically questionable act. The recompense for donation would be an incongruent violation of personal rights. At the present time, there does not appear to be a satisfactory solution to this dilemma. The only solution that could be put forward would be to ask the donor to voluntarily inform the recipient of his/her seropositivity.

[Patient information: management in the beginning of the XXIth century]

The Conseil d'Etat, the supreme jurisdiction on legislative matters in France, rendered its decree on January 5, 2000, founding its decision on jurisprudence established in 1997 and 1998 by the supreme Court of Appeals. In accordance with this decision, physicians have a legal obligation to inform patients of all possible risks, including very exceptional risks. The information may be given to the patient in any appropriate form. Proof that information was delivered to the patient is incumbent upon the physician. When proof of information delivery is provided, any injury compensation can only be awarded on the grounds of ill-fate. We conducted an objective review of the jurisprudence on patient information and report the three basic aspects observed in the current situation in France. In application of the Court of Appeals judgments of February 25, 1997 and October 14, 1997, proof of delivery of information to the patient is incumbent upon the physician. The question is whether the physician must retain written documents as necessary proof against future claims. The answer to this question is not straightforward. A written document is not the only proof accepted by the court and could even be of debatable legal value if used inappropriately. The solution retained by the Conseil d'Etat is a good example. The real debate concerns the information content. It now appears that the physician is required to inform his/her patient of all risks susceptible of influencing the patient's decision, particularly serious or life-threatening risks, but also, and most certainly, risks that in the past have been considered frequent but benign. Finally, the judges recall that failure to provide information does not in itself assert the physician's civil responsibility, proof of real damage is also needed. But the reality of damage (ill-fate) depends on the reality of the choice open to the patient had he/she been informed. And the true nature of the choice open to the patient is simply the expression of the dispensable or indispensable nature of the envisaged act. One could say the old adage primum non nocere is making a comeback.