Ballistic Injuries PDF

9 Ballistic injuries ▪▪ Introduction ▪▪ Evidence recovery ▪▪ Types of firearms ▪▪ Blast injuries ▪▪ Firearms injuries ▪▪ Mass disasters ▪▪...

9 Ballistic injuries ▪▪ Introduction ▪▪ Evidence recovery ▪▪ Types of firearms ▪▪ Blast injuries ▪▪ Firearms injuries ▪▪ Mass disasters ▪▪ Air weapons, unusual projectiles and other weapons ▪▪ Bibliography and information sources ▪▪ Determination of accident, suicide or murder ▪▪ Further general resources Introduction that propel the projectile(s). Airguns and air rifles form a separate group of weapons that rely upon compressed The unlawful use of firearms as weapons of assault gas to propel the projectiles. These weapons, and more continues to increase. Firearms are relatively easy to unusual forms of projectile or firearm, such as the rub- obtain, whether in jurisdictions where their possession ber bullet, stud (also known as power-actuated or nail) is controlled and use is permitted or not. Legislation guns and humane killers, are considered at the end of this intended to reduce availability often seems to have section. an impact only on those with a lawful need or reason Modern propellants consist of nitrocellulose or for possession, rather than on those intent on using other synthetic compounds prepared as small coloured firearms for criminal purposes. In whichever jurisdic- flakes, discs or balls. During the process of firing a bullet tion the forensic practitioner practices, he or she will or shotgun cartridge the following sequence of events encounter injury and death caused by a wide variety of occurs: the firing pin strikes the primer cup and the firearms. Often the availability and control of firearms primer compound explodes; small vents between the is a focus of intense political debate. The nature of the primer cup and the base of the cartridge case allow the firearm is often dependent on the jurisdiction. Firearm flame of this detonation to spread to the propellant; the injury may be deliberate (as in conflict or assault) or propellant burns rapidly, producing large volumes of accidental or unintentional (e.g., hunting injuries). gas, which are further expanded by the very high tem- peratures of the ignition; and the pressure of this gas Types of firearms propels the shot or bullet from the barrel. The speed with which the projectile leaves the end of Within England & Wales a firearm is ‘a lethal barreled the barrel (the muzzle velocity) varies from a few hun- weapon of any description from which any shot, bullet or dred metres per second in a shotgun to a thousand or other missile can be discharged’ (section 57 (1) Firearms more in a high-velocity military weapon. The energy of Act 1968). It includes: the projectile is proportional to the speed at which it Any prohibited weapon (see below in this guid- travels and is calculated from the kinetic energy (½MV2) ance section 5 Firearms Act 1968), whether it is of the bullet. Higher muzzle velocities are considerably such a lethal weapon as aforesaid or not. more effective at delivering energy to the target than Any component part of such a lethal or prohibited larger bullets. The extent of injury, and wound pattern, weapon. created by a firearm is, in part, directly related to the Any accessory to any such weapon designed or muzzle velocity. adapted to diminish the noise or flash caused by firing the weapon. Shotguns The term ‘lethality’ itself is a complex issue and Shotguns, commonly used in the sport, hunting and although case law exists (Moore v Gooderham 3 farming sectors, are long-barrelled, smooth-bore fire- All E.R. 575), only a court can decide whether any par- arms that are used to discharge cartridges that usually ticular weapon is a ‘firearm’ for the purposes of the Acts. contain a number of shot. These guns may have single There are two main types of firearm: those with or double barrels, commonly 26–30 inches (66–76 cm) smooth barrels, which fire groups of pellets or shot, and in length; the double-barrelled weapons are arranged those with grooved or rifled barrels, which fire single pro- either ‘side by side’ or ‘over and under’. The length of the jectiles or bullets. Both of these types of weapon rely upon barrel makes handling and concealing shotguns dif- the detonation of a solid propellant to produce the gases ficult and so it is not uncommon for the barrels to be 134 Ballistic injuries (a) (b) calibre, shot size and distance at which the shotgun was Case discharged from the target (see below). Rifled firearms Shot This group of firearms usually fire one bullet at a time through a barrel that has had a number of spiral grooves Wad cut into the bore. The resultant projections, referred to as ‘lands’, engage with the bullet and impart gyroscopic Powder spin that produces a more stable and accurate trajec- charge tory. Rifled weapons fall into two main groups: hand guns and rifles. Brass head Revolvers and pistols are short-barrelled hand guns. Revolvers contain a rotating cylinder into which car- Primer tridges are manually loaded. Pistols, or semi-automatic Figure 9.1 Shotgun cartridge structure: (a), image of a hand guns, usually contain a magazine enclosing the shotgun cartridge; (b), diagram of structure of typical cartridges located within the grip. The firearm is dis- cartridge. charged when the cocked firing pin, or striker, impacts on to the primer cup in the base of the cartridge by pull- ing the trigger. The main difference in the two types of shortened for criminal activities. This shortening of the firearm is the method of operation (Figure 9.2). barrel has little impact on the effectiveness of the gun, In the revolver, the cylinder rotates to align a new especially over short to middle distances. A shotgun cartridge with the firing pin and the barrel, which is generally has an effective range of about 30–50 m. achieved by either pulling the trigger (double action) The cartridges for shotguns (Figure 9.1) consist of a or by manually cocking the hammer and subsequently metal base, or head, containing a central primer cap, pulling the trigger (single action). The fired cartridge supporting a cardboard or plastic tube containing the cases remain in the gun until they are manually propellant charge and the shot, which is closed by a thin unloaded. disc or a crimp at the end of the tube. The shot may be In a pistol, the forces generated each time a cartridge is contained within a plastic wad or there may be discs of discharged are used to recycle the weapon, which involves felt, cork or cardboard, acting as wads above and below extracting and ejecting the fired cartridge case, resetting the shot. The plastic wads open into a petal-shape the firing mechanism and loading a new cartridge from in flight and may themselves contribute to an injury, the magazine into the chamber. For semi-automatic especially at close range. weapons this occurs each time the trigger is pulled. Shotgun cartridges are designated according to the Rifles are long-barrelled weapons that are designed to size of the individual shot contained within and can accurately fire projectiles at targets at a much greater dis- vary significantly in number depending on the shot tance than revolvers or pistols. Rifles have been designed size (typically 6–850 in number for a 12-bore cartridge). to use many different types of operating mechanism, There are also cartridges that contain a single heavy ranging from single shot bolt-action rifles to fully auto- projectile, commonly referred to as a ‘slug’. The types of matic gas-operated assault rifles, some of which are wound produced by a shotgun will be dependent on the capable of firing in excess of 700 cartridges per minute. (a) (b) Figure 9.2 Revolvers and pistols. (a) Heckler & Koch USP (Universal Service Pistol), Germany, 1993. Calibre 9 mm para- bellum. (b) Ruger GP–100, USA, 1987. Calibre.357 Magnum.  Firearms injuries 135 Firearms injuries Injuries sustained from discharge of firearms can origi- nate from the smoke, flame and gases of combustion (as well as the projectile). These exit the barrel, together with portions of unburned, burning and burnt pro- pellant and other items such as wadding and plastic containers for the pellets. These items and particles will usually follow the projectile(s), but in some guns they may also precede them. The distance they will travel from the end of the muzzle is extremely variable, depending mainly on the type of weapon and the type of propellant. They can also escape from small gaps around the breech and will soil hands or clothing close to the breech at the time of discharge. The presence, location and distribution of such items and particles may have substantial evidential value in the forensic investigation of a shooting incident, and determining who fired or handled the weapon (see Box 9.1). Injuries from smooth-bore guns Discharge from a cartridge forces pellets along the barrel by the gases of detonation. The pellets leave the muzzle in a compact mass, the components of which spread out as it travels away from the gun. The shot pat- Figure 9.3 A 9 × 19 mm Luger semi-automatic pistol tern expands as a long, shallow cone with its apex close cartridge (left), and a NATO 5.56 × 45 mm automatic rifle to the muzzle of the shotgun. The further away from the cartridge (right). gun the victim is situated, the larger the pellet spread, and the larger the area of potential damage (Figure 9.4). The cartridges for rifled weapons consist of a metal cartridge case, usually constructed of brass, steel or alu- minium, a primer cup located in the base, propellant contained within the cartridge case and a single bullet Box 9.1 The forensic investigation of fitted into the mouth of the case. The size and design of shooting incidents the cartridge is dependent on the weapon in which it is The forensic recovery of evidence generated at to be used and the desired ballistic performance of the the scene of the discharge of a firearm assists with projectile. Rifle cartridges usually have a larger case to reconstruction of the incident, and in particular, the bullet ratio, thus a larger propellant load, than hand gun assessment of projectile trajectory and range-of-fire. cartridges. This is due to the fact that rifle cartridges are The examination of fired bullets and cartridge cases required to be effective over a much greater distance (up recovered from the shooting scene can be used to to 2 km) (Figure 9.3). compare the marks observed with those produced Bullet size (or calibre) and design vary and are pri- from the discharge of a firearm suspected to have marily concerned with ballistic performance and the been used in the crime. This information can then ability of the projectile to transfer its kinetic energy to be entered into a firearms database that allows the the target on impact. The formation of wounds is related determination of links between scenes at which the to the transfer of the energy of the bullet to the body tis- same firearm may have been used and to establish sues, and many types of ammunition are specifically gun crime trends, both nationally and internationally. designed to result in specific wound patterns. In addition, forensic scientists can use specialist Expanding bullets, also known as Dum-Dum bullets, equipment to determine the velocity and kinetic are projectiles designed to expand on impact, increasing energy of a projectile in flight, which can be used to in diameter to limit penetration and/or produce a larger establish the ballistic performance of a projectile and diameter wound for faster incapacitation. Two typical the lethality of a weapon/ammunition combination. designs are the hollow-point bullet and the soft-point In the UK, this is routinely used to determine if air bullet. The Hague Convention of 1899, Declaration III weapons have lethal potential or are especially dan- prohibits the use of expanding bullets in international gerous according to current UK firearms legislation. warfare. 136 Ballistic injuries (a) (b) 4 3 2 1(a) 6 5 1(b) Figure 9.4 Variation in appearance of a shotgun wound at Figure 9.6 Firm contact entrance wound just above the increasing range of discharge: (a)/1(a), split wound from umbilicus from a twelve-bore shotgun. Clothing pre- contact over bone; (b)/1(b), usual round contact wound; vented soot soiling, but minor peripheral abrasions were 2, close but not contact range up to approximately 30 cm caused by impact of a belt. Gas expansion in the disten- (variable); 3, ‘rat hole’ (scalloped) wound from 20 cm sible abdomen has prevented skin splitting at the wound to approximately 1 m (variable); 4, satellite pellet holes edges. (Reproduced with permission from Saukko P and appearing over approximately 2 m; 5, spread of shot Knight B. Knight’s Pathology 4E, London, CRC Press, 2016.) increases, central hole diminishes; 6, uniform spread with no central hole over approximately 10 m. All these ranges may usually be recovered from the wound track. The tis- vary greatly with barrel choke, weapon and ammuni- sues along the wound track may be blackened and the tion. (Reproduced with permission from Saukko P and surrounding tissues are said to be pinker than normal Knight B. Knight’s Pathology 4E, London, CRC Press, 2016.) supposedly as a result of the carbon monoxide contained within the discharge gases creating carboxyhaemoglo- Contact wounds are created when the gun muzzle bin. As with most colour descriptions in forensic medi- abuts the skin and usually results in a circular entrance cine, the theory is not always clearly backed up by the wound that approximates the size of the muzzle (Figures findings. 9.5 and 9.6). The wound edge will be regular and often A close discharge, within a few centimetres of the has a clean-cut appearance with no individual pellet skin surface, will also produce a wound with a similar marks apparent. Often there will be smoke soiling of at appearance, but as for the muzzle gases can escape, least some of the margin of the wound. There may be a there will be no muzzle mark (Figure 9.7). More smoke narrow, circular rim of abrasion around some or all of soiling can occur, and burning of skin, with singe- the entrance wound, caused when the gases of the dis- ing and clubbing of melted hairs, may be seen around charge enter through the wound and balloon the tissues the wound (Figure 9.8). Powder ‘tattooing’ of the skin upwards so that the skin is pressed against the muzzle. around the entry wound may be evident. This tattoo- If the discharge was over an area supported by bone, ing results from burnt and burning flakes of propellant the gases cannot disperse as readily as they would in causing tiny burns on the skin and cannot be washed soft, unsupported areas such as the abdomen, and the off. As with contact discharges, wads will often be found greater ballooning of the skin results in splits (lacera- in the wound track. tions) of the skin, which often have a radial pattern. In At intermediate ranges (between 20 cm and 1 m), contact wounds, any wadding or plastic shot containers there will be diminishing smoke soiling and burning of Figure 9.5 Suicidal twelve-bore shotgun entrance wound, with soot soiling. The wound shows the outline of the Figure 9.7 A close-range shotgun entrance wound with non-fired muzzle, indicating that the weapon was a minimal scalloping of the edges, some soot staining, double-barrelled shotgun pressed against the skin at dis- and peripheral stippling. (From Burton J, Saunders S, charge. (Reproduced with permission from Saukko P and Hamilton S. Atlas of Adult Autopsy Pathology. Boca Raton: Knight B. Knight’s Pathology 4E, London, CRC Press, 2016.) CRC Press; 2015 (Fig. 2.38a page 47), with permission.)  Firearms injuries 137 Figure 9.8 Suicidal close range discharge of a twelve- bore shotgun wound to the chest. This wound has torn Figure 9.10 Upper left thigh injury caused by interme- a large ragged defect in the chest wall and there is soot diate discharge of both barrels of sawn-off shotgun discolouration at the medial wound edge because of the to outer leg – bruising, swelling, massive soft tissue tangential orientation of the discharge. ­disruption caused by discharge. on generalisations about the ratio of the diameter of the skin, but powder tattooing may persist. The spread this spread to the range are unreliable. At long ranges of shot will begin, first causing an irregular rim to the (>20–50 m), there is a uniform peppering of shot, and wound. This is called a ‘rat-hole’ because of the appear- this is rarely fatal although lifechanging injuries can ance of the wound edge; the term ‘scalloping’ may also occur, such as loss of eyes (Figure 9.11a–c). be used. Additional injuries, sometimes remote from Shotguns rarely produce an exit wound when fired the entrance wound, caused by the wads or plastic shot into the chest or abdomen, although single-pellet exit containers may be seen (Figure 9.9). Substantial tissue wounds can occasionally be seen. Exit wounds can damage may occur when both barrels are fired simul- be seen when a shotgun is fired into the head, neck or taneously (Figure 9.10). mouth. The exit wound in these cases may be a huge At a range of over 1 m, smoke damage and tattooing ragged aperture, especially in the head, where the skull are generally absent and the nature of such longer may virtually explode with the gas pressure from a con- range injuries will depend upon the spread of the shot, tact wound, ejecting part or even all of the brain from which in turn is ­dependent upon the construction of the cranial cavity (Figure 9.12). the barrel. With a normal length barrel shotgun, satel- lite pellet holes begin to be seen around the main cen- Wounds from rifled weapons tral wound at a range of about 2–3 m. It is important to ­document the spread of the shot so that if the weapon Bullets fired from rifled weapons, generally at a higher is recovered, test firings using identical ammunition velocity than pellets from a smooth-bore weapon, will can be performed to establish the range at which a commonly cause both an entry and an exit wound. particular spread of shot will occur. Estimates based However, many bullets are retained within the body because they did not possess enough energy to com- plete the passage through it, or energy was dissipated on contact with other structures (e.g., bone). A bullet has an upper limit of wounding potential derived from its mass and velocity. Wound severity is related to the bullet construction and its trajectory, as well as the properties of the body tissues traversed. Entrance and exit wounds Contact wounds from a rifled weapon are generally cir- cular, unless over a bony area such as the head, where splitting caused by the propellant gas is common (Figure 9.13). There may be a muzzle mark on the skin surface if Figure 9.9 Abraded bruise surrounding an intermediate- the gun is pressed hard against the skin, and a pattern range homicidal shotgun entrance wound, caused by may be imprinted from a foresight or self-loading mech- impact against the skin from the opening up of the plas- anism. There may be slight escape of smoke, with some tic wadding. Note the scalloping of the wound edges. local burning of skin and hair, if the gun is not pressed 138 Ballistic injuries (a) Figure 9.12 Suicidal twelve-bore shotgun entrance (b) wound in a ‘site of election’ under the chin. The cir- cular soot discoloration on the skin surface indicates a very close (or even ‘loose’ contact) discharge. Note the extensive destruction reflecting the explosive effect of shotgun discharges to the head. (Reproduced ­ ermission from Saukko P and Knight B. Knight’s with p Pathology 4E, London, CRC Press, 2016.) tightly. Bruising around the entry wound is not uncom- mon (Figures 9.14 and 9.15). At close range (up to about 20 cm), there will be some smoke soiling and powder burns, and skin and hair may (c) be burnt, although this is variable and depends upon both the gun and the ammunition used. The shape of the entry wound gives a guide to the angle that the gun made with that area of skin: a circular hole indicates that the discharge was at a right angle to the skin, whereas an Bone Figure 9.11 (a) Distant-range shotgun entrance wound, with a central hole surrounded by peripheral satellite pellet holes. This wound was caused by discharge from Cratered on approximately 4 m; measurement of shot-spread can be inner surface compared with that created from test-firing the suspect weapon and ammunition to provide a more accurate assessment of range of fire. (b) Pellet injuries from a medium range twelve-bore shotgun discharge (approxi- mately 7–9 m, excluding the possibility of a suicidal dis- charge). (c) Shotgun pellet injury to skin from discharge Figure 9.13 A firm contact discharge of a fired weapon about 12 m away. ([b] From Saukko P, Knight B. Knight’s against tissue overlying bone (e.g., the skull) causes Forensic Pathology, 4th ed. Boca Raton: CRC Press; 2016, expanding hot gases to be forced backwards towards the Figure 8.20 with permission.) barrel, raising a dome under the skin, causing it to split. This can give rise to a ragged entrance wound. (From Saukko P, Knight B. Knight’s Forensic Pathology, 4th ed. Boca Raton: CRC Press; 2016 [Fig 8.38 page 256].)  Firearms injuries 139 Figure 9.16 Circular distant gunshot entrance wound from a rifle bullet. There is no associated soot soiling or burning of the wound edges, with only minimal ­marginal abrasion and bruising. (Reproduced with Figure 9.14 Close-range gunshot entrance wound from ­permission from Saukko P and Knight B. Knight’s a pistol, with powder tattooing on the adjacent skin. Pathology 4E, London, CRC Press, 2016.) The eye is blackened as a result of bleeding ‘tracking’ down from fracturing of the anterior cranial fossa in the (Figure 9.17). No burning, smoke or powder soiling will skull base. (Courtesy of Richard Jones.) be evident. If the bullet has been distorted or fragmented, or if it has fractured bone, the exit wound may be consid- oval hole, perhaps with visible undercutting, indicates erably larger and more irregular, and those fragments of a more acute angle. bullet or bone may cause multiple exit wounds, poten- Examination of the entry wound will show that tially leading to difficulties in interpretation. the skin is inverted; the defect is commonly slightly Where skin is firmly supported, as by a belt, tight smaller than the diameter of the missile because of the clothing or even a person leaning against a partition elasticity of the skin. Very commonly, there is an ‘abra- wall, the exit wound may be as small as the entrance and sion collar’ or ‘abrasion rim’ around the hole, which is may fail to show the typical eversion. To increase the caused by the friction, heating and dirt effect of the mis- confusion, it may also show a rim of abrasion, although sile when it indents the skin during penetration. Bruising this is commonly broader than that of an entry wound. may or may not be associated with the wound. The internal effects of bullets depend upon their When the discharge was from >1 m or so, there may kinetic energy. Low-velocity, low-energy missiles, such be no smoke soiling, burning or powder tattooing. At as shotgun pellets and some revolver bullets, cause longer ranges (which may be up to several kilometres simple mechanical disruption of the tissues in their with a high-powered rifle), the entrance wound will path. High-velocity bullets, however, cause far more have the same features of a round or oval defect with an damage to the tissues as they transfer large amounts of abrasion collar (Figure 9.16). At extreme ranges, or fol- energy, which results in the formation of a temporary lowing a ricochet, the gyroscopic stability of the bullet cavity in the tissues. This cavitation effect is especially may be lost and the missile begins to wobble and even pronounced in dense organs, such as liver and brain, tumble, and this instability may well result in larger, but occurs in all tissues if the energy transfer is large more irregular wounds. enough and can result in extensive tissue destruction The exit wound of a bullet is usually everted with split flaps, often resulting in a stellate appearance Figure 9.17 Typical exit wound with everted, split edges, Figure 9.15 Suicidal contact gunshot entrance wound with no soiling of the surrounding skin. (Reproduced to the temple. The skin is burnt and split because from Saukko P, Knight B. Knight’s Forensic Pathology, of the effects of the discharge products. 4th ed. Boca Raton: CRC Press; 2016, Figure 8.31, (Courtesy of Richard Jones.) with p ­ ermission.) 140 Ballistic injuries Box 9.2 The death of President J.F. Kennedy At approximately 1230 hours on Friday, 22nd November Series); Dr. Peter Cummings, a Forensic Pathologist, 1963, the President of the United States of America, examined the original autopsy photographs and X-rays, John F. Kennedy, was shot whilst travelling in an open- and clothing worn by JFK (the brain has not been found) top car being driven through Dallas, Texas. He was and considered the skull f­racture pattern – linear frac- taken to the nearby Parkland Hospital where he was tures radiating forwards and upwards from the back of pronounced dead at 1300 hours. Medicolegal investi- the right side of the head, with perpendicular curved gation into his death has been the subject of intense fractures connecting them – to ­represent the effects of controversy ever since; his body was taken out of the a shot to the back of the right side of the head, and not jurisdiction of Dr. Earl Rose, the Dallas County Medical from the front of the head as many commentators have Examiner, without his agreement, and an autopsy was claimed. The ballistics examination of the rifle, and full performed by two Navy Pathologists and one Forensic metal jacket ammunition used, showed convincingly Pathologist with limited practical experience in a mili- that wounds to JFK and Governor John Connelly could tary hospital in Bethesda, between 2000 and 2300 be explicable on the basis of two ­gunshots from the hours on the same day of his death. Texas Book Depository. The autopsy documentation has been heavily criti- The consequences of an inadequate foren- cised – few photographs were taken, blood-stained sic autopsy in such a high-profile death have been contemporaneous notes were destroyed, and there immense and, following the publication of the Warren was confusion as to the interpretation of the wounds Commission Report in 1964, and that of the House found. The main source of dispute is in relation to the Select Committee on assassinations in 1979, there is number of gunshot wounds, their tracks within the continued speculation about the exact nature of events head and neck, and whether they represent entrance leading to JFK’s death, which is likely to continue indefi- or exit wounds. nitely due to the absence of key evidence and trusted The absence of detailed dissection contributed to documentation. This is the case for many historically the confusion regarding a set of wounds to the back and important but historically remote deaths, and provides front of the neck (altered by emergency surgical inter- much opportunity for documentary makers, authors vention to create a tracheostomy) and the p ­ recise loca- and amateur sleuths. tion of an entrance wound at the back of the head. The ballistic and forensic pathological evidence has been Source: Wilber CG. Medicolegal Investigation of the President recently scrutinised on behalf of PBS America (the p ­ ublic John F. Kennedy Murder. Springfield: Charles C Thomas broadcasting service, and broadcasted via the NOVA Publisher; 1978. away from the wound track itself. The cavitation effect common ways in which the gas is compressed. The sim- may be exacerbated by the radial stretching of tissues plest method employs the compression of a spring which, creating a temporary wound cavity. when released, moves a piston along a cylinder; more The importance of an adequate description of gun- powerful weapons use repeated movements of a lever shot wounds at autopsy is illustrated very well by the to pressurise an internal cylinder. The third type has an ongoing controversy surrounding the death of US internal cylinder which is ‘charged’ by connecting it to a President John F Kennedy in 1963 (Box 9.2), and sub- pressurised external source. The barrel of an air weapon stantial tissue damage and loss, and unknown other may or may not be rifled; the more powerful examples factors (e.g., d ­ irection of wound track, distance from have similar rifling to ordinary handguns and rifles. weapon) all impact on the extent to which reliability The energy of the projectile will depend mainly on can be placed on the conclusions drawn. This, how- the way in which the gas is compressed: the simple ever, does not appear to prevent people coming up with spring-driven weapon is low powered, while the more their own theories, in which speculation and general complex systems can propel projectiles with the same assumptions play a large part. energy, and hence at approximately the same speed, as many ordinary handguns. The injuries caused by the projectiles from air weap- Air weapons, unusual ­projectiles ons will depend upon their design, but entry wounds and other weapons from standard pellets are often indistinguishable from those caused by standard bullets in that they have a Air guns and rifles defect with an abrasion rim. The relatively low power of Air weapons rely upon the force of compressed air to pro- these weapons means that the pellet will seldom exit, pel the projectile, usually a lead or steel pellet although but if it does do so, a typical exit wound with everted darts and other projectiles may be used. There are three margins will result.  Air weapons, unusual ­projectiles and other weapons 141 Miscellaneous firearms and weapons A number of other implements may fulfil the criteria for firearms while others may mimic their effects. It is appropriate to have an understanding of the nature and mechanics of such implements to take their possible effects into consideration when determining injury cau- sation. In public disorder situations, a variety of Kinetic Energy Devices (KED) are available to law-enforcement or security organisations. These ‘impact devices’ are intended to deliver an impact of sufficient force to dis- suade or prevent an acutely behaviourally disturbed person from harming others (or themselves). A wide range of KEDs are available around the world. They are not intended to cause serious, life-changing or life- threatening injury, although serious injury and fatalities do occur. KEDs are known by a variety of names, includ- ing plastic bullets, rubber bullets, baton rounds, impact rounds and attenuating energy projectiles (AEP). The Figure 9.18 Attenuated energy projectile (AEP). names are not used consistently in the literature. Impact rounds are made from materials of lower density than standard bullets, are larger, and fired at lower velocities. diameter and when discharged has a muzzle velocity of Impact rounds have a complex balance between effec- ~69 ms -1. Marks left on the skin surface by KEDs may tiveness and unintended consequences. Many rounds be patterned and distinctive to that particular device. may be safe and effective when they strike one part of The most vulnerable areas in terms of potential for seri- the body, but may cause serious injury or even death if ous or life-threatening injury from KEDs are: the head, they strike a vulnerable area of the body. facial skeleton, brain, eyes: the thorax, rib fractures, Accuracy of targeting is thus a key attribute of these lung contusion/laceration, heart injury; the abdomen types of round if unintended injuries are to be mini- and all intra-abdominal organs (solid and hollow) are mised. The projectiles are often cylinders made of rub- vulnerable to some forms of non-penetrating impact. ber, plastic, wood, or foam, and can be as large as the Injuries and deaths from stud guns (or power-acti- full-bore diameter of the launcher. Another type of KED, vated or nail-guns) are well recorded. Stud guns are is the ‘beanbag projectile’ which consists of a tough fab- devices used in the building industry to fire steel pins ric bag filled with compliant material. The beanbag flat- into masonry or timber by means of a small explosive tens on impact maximizing the area of surface contact. charge. They have been used for suicide and even homi- Since 2005, the UK Home Office currently permits the cide, but accidental injuries are more common often to police the use of a bespoke blunt impact round referred the eye and head. The skin wound often appears similar to as the Attenuating Energy Projectile (AEP) as a less to many small-calibre entry wounds, although the find- lethal support to firearms operations (see Figure 9.18). ing of a nail on exploration or from imaging techniques The approved AEP (designated as L60A2) is fired from a will usually solve the diagnostic problem. 37 mm breech loaded weapon. The approved launcher Humane killers are devices used in abattoirs, and by is the Heckler and Koch L104A2, equipped with an veterinary surgeons, to stun animals before slaughter. approved L18A2 optical sight. The projectile has been They may fire either a small-calibre bullet or a ‘captive designed with a nose cap that encloses a void. This bolt’, where a sliding steel pin is fired out for about 5 cm design feature is intended to attenuate the delivery of the by an explosive charge. The skin injury will depend on impact energy by extending the duration of the impact the type of weapon used. These weapons have been used and minimising the peak forces. It thereby delivers a for both homicide and suicide, but accidental discharges high amount of energy to maximise its effectiveness, are also recorded and may cause serious injury or death. while reducing the potential for life-threatening inju- Bows and crossbows are used recreationally but ries. Operational use of the AEP in the UK police service may also be used as weapons of assault and cause both is limited to authorised officers who have been specifi- fatal and non-fatal injuries. These weapons fire arrows cally trained in use of the system. They are rarely fired or bolts, which are shafts of wood or metal with a set of in mainland UK; perhaps 10–20 occasions per annum flights at the rear to maintain the trajectory of the projec- although the most recent (2018) date indicate they were tile. The tips of these projectiles may have many shapes deployed on 530 occasions in the preceding year. These from the simple point to complex, often triangular, data are published regularly by the UK government. A forms. The shape of the entrance wound depends on the typical impact round is about 100 mm long, 35 mm in type of arrowhead: broadheads produced star-shaped 142 Ballistic injuries Sight (style varies) Serving Latch String Arrow retention spring Flight groove Stock Riser Sight bridge Trigger Foregrip Cocking Barrel Limb stirrup Figure 9.19 A typical crossbow. to triangular wounds, field-tips caused circular, oval or slit-like injuries (Figure 9.19). Box 9.3 Human Rights law and a The energy produced is extremely variable, depend- ­firearms-related death ing on the construction of the weapon. The injuries caused depend on the energy of the projectile as well Abdulmenaf Kaya was shot dead in 1993. His brother as on its construction. However, if the projectile has a alleged that he was deliberately killed by security simple pointed tip, and if it has been removed from the forces, but the government stated he had been body, the entry wounds can appear very similar to those killed in a gun battle between security forces and a caused by standard bullets, with a central defect and group of terrorists. surrounding abrasion rim. A case was brought to the European Court of Human Rights against the Turkish government under Article 2 (‘Right to Life’) alleging unlawful kill- Determination of accident, s­ uicide ing but the Court found no violation. The govern- or murder ment did, however, fail to comply with an obligation to make an effective investigation into the death, in The determination of the circumstances in which an violation of procedural obligations inherent in the individual has died from a firearm injury is crucial. article. Where a firearms-related death occurs in circum- Specific deficiencies in the medicolegal investiga- stances in which the police or security service personnel tion of this death were: performing a hasty autopsy may be involved, an effective investigation by the State – ‘in the field’; failure to record the number of bullets including an adequate autopsy – is a requirement under striking the deceased, and a failure to determine human rights law (Box 9.3). range of fire; and failure to test for gunpowder traces Those who investigate deaths and those who contrib- on the deceased’s clothing or body; failure to con- ute to the investigation, including forensic pathologists sider any scenario other than ‘lawful killing’ by secu- and forensic physicians, must always consider the possi- rity forces, rather than an arbitrary killing by agents bility of ‘staging’ of homicide in order to give the appear- of the State. ance of death having occurred as a result of accident or suicide. For those who have killed themselves, it should be expected that the wounds are both in an accessible Source: Kaya vs Turkey, 158/1996/777/978 Judgement of site and range of the deceased’s arm, unless some other 19th February 1998. device has been used to reach and depress the trigger. The  Evidence recovery 143 Box 9.4 Activity capability following gunshot wounds Activity capability following a gunshot wound to the It had started to snow about an hour and a half before head* the man returned to his accommodation, and footprints An elderly man with financial and domestic difficulties, were present in snow, as well as blood spots around the who erroneously thought he had cancer, left his private shelter and to the private hotel. Letters written by him hotel, on a winter’s night, returning the next morning the day before indicated his intention to kill himself. with blood on his face. He told the maid that he was going upstairs to the bathroom, where he collapsed and Activity capability following a shotgun wound to the lost consciousness. He died a few hours later, and was chest** found to have a gunshot wound under his chin; powder Forensic pathologist DiMaio recounted a case involv- was found in the wound (but not on the skin) and the ing substantial injury to the heart of a young man wound track passed upwards through the mouth and shot in the chest with a 12-gauge shotgun, at a range into the skull just behind the roof of the left orbit, where of 3–4 feet, which ‘literally shredded’ the heart; he it continued through the left cerebral cortex to exit the was capable of running 65 feet (20 metres) before skull through the left frontal bone, causing extensive lac- collapsing. eration to his brain. On retracing his steps, the man’s 45 Colt revolver was * Smith S. Voluntary acts after a gunshot wound of the brain. Police J 1943;16:108–110. found on a seat in a shelter in nearby gardens, at the site ** D iMaio VJM. Bloody bodies and bloody scenes. In: DiMaio of a large pool of blood, and there was a bullet hole and VJM. Gunshot Wounds: Practical Aspects of Firearms, Ballistics fragments of bone and brain on the roof of the shelter and Forensic Techniques, 2nd ed. Boca Raton: CRC Press; 1999, above the seat. 254. weapon must be present at the scene, although it may be fatal, as is demonstrated by the cases described in at a distance from the body because it may have been cat- Box 9.4. It is most likely that severe damage to the brain, apulted away from the body by the gun recoil, or by move- heart, aorta and any number of other vital internal ment of the individual if death was not instantaneous. organs will lead to rapid collapse and death; however, The deceased’s DNA or fingerprints should be present many forensic practitioners will have seen cases of sur- on the weapon (unless gloves were worn). Suicidal gun- vival (sometimes long-term) following a contact dis- shot i­ njuries are most commonly in the ‘sites of e­ lection’, charge of a firearm into the head. which vary with the length of the weapon used. Both long-barrelled and short-barrelled weapons can be used in the mouth, below the chin, on the front Evidence recovery of the neck, the centre of the forehead or, more rarely, In the living, all efforts must be directed to saving life but, the front of the chest over the heart. Discharges into the if at all possible, the emergency medicine specialist, and temples are almost unique to handguns and are usu- surgeon, should make good notes of the original appear- ally on the side of the dominant hand, but this is not an ances of the injuries and preferably take good-quality absolute rule. People rarely shoot themselves in the eye images of any entry or exit wounds before any surgical or abdomen or in inaccessible sites such as the back. It cleaning or operative procedures are performed. Intra- is unusual for females to commit suicide with guns and operatively it is useful to record the nature and direction females are rarely involved in firearms accidents. of possible wound tracks, and their length. Any foreign If suicide can be ruled out by the range of discharge, objects such as wads, bullets or shot, and any skin removed by absence of a weapon or by other features of the injury from the margin of a firearm wound during treatment, or the scene, a single gunshot injury could be either should be carefully preserved for the police. The presence accident or homicide. Multiple firearm wounds strongly of a forensic physician at the time can be helpful in ensur- suggest homicide. However, there have been a number ing that appropriate documentation is made, for presenta- of published reports of suicidal individuals who have tion at a later stage in court. Ideally, the police should be fired repeatedly into themselves even when each wound contacted (with the individual’s consent) should surgical is potentially fatal. The distinction between homicide, intervention be required so that a ‘chain of custody’ for suicide and accident can sometimes be extremely dif- evidence can be established. ficult and a final conclusion can only be reached after a Those arrested for possible involvement in firearms full medicolegal investigation. offences will need detailed examination and taking of It is as unwise to state that a gunshot wound, as with samples, including skin and hand swabs, and nasal any other sort of injury, must have been immediately samples, to identify any firearms residue. Standardised 144 Ballistic injuries and approved processes should be applied to all these vicinity solely from the effects of the wave of high pres- forms of trace evidence collection. sure and hot gases striking the body. A minimum pres- The same general rules apply to the post mortem sure of about 700 kPa (100 lb/inch 2) is needed for tissue recovery of exhibits. The skin around the wounds may damage in humans. There will also be pressure effects be swabbed for powder residue if this is necessary, but upon the viscera and these effects are far more damag- the retention of wounds themselves is no longer consid- ing where there is an air–fluid interface, such as in the air ered to be essential. Swabs of the hands of the victim passages, the lungs and the gut. Rupture and haemor- should be taken. The pathologist must ensure that accu- rhage of these areas represent the classical blast lesion. rate drawings and measurements of the site, size and Blast injuries can be categorised as primary to qua- appearance of the wound are obtained and that distant ternary injuries. Primary injuries result from the effect and close-up photographs are taken of each injury with of transmitted blast waves on gas-containing structure an appropriate scale in view. (e.g., thorax); secondary injuries result from the impact In many countries, all firearm wounds, whether or of airborne debris; tertiary injury results from transpo- not they are fatal, must be reported to the police, irre- sition of the entire body due to blast wind or structural spective of the consent of the injured individual. The collapse, and quaternary injuries make up the remain- UK General Medical Council advises, having reiterated der, including burns. Quinary blast injuries have also the duty of confidentiality, ‘the police should usually be been proposed: the clinical consequences of post-deto- informed whenever a person presents with a gunshot nation environmental contamination such as bacteria. wound. Even accidental shootings involving lawfully Although the primary effect of blast is large, in held guns raise serious issues for the police about, for most cases many more casualties, fatal and otherwise, example, firearms licensing’. are caused by secondary and tertiary effects of explo- sive devices, especially in the lower-powered terrorist Blast injuries bombs. These effects include: Armed conflict and terrorist activity lead to many deaths Burns – directly from the near effects of the explo- from explosive devices. Domestic and international sion and secondarily from fires started by the terrorist activity is now present in many countries and bomb. therefore there has been an increase in the experience Missile injuries from parts of the bomb casing, of medical personnel in the assessment and treatment of contents or shrapnel or from adjacent objects. blast (explosive) injuries. They may derive from a number Peppering by small fragments of debris and dust of sources including improvised explosive devices (IEDs), propelled by the explosion (Figure 9.20). car bombs and suicide bombers. The nature of the explo- Various types of injury owing to collapse of struc- sive device may alter the nature of injury, and the position tures as a result of the explosion. or activity of the individual (e.g., in a vehicle, on foot) at The body impacting against other structures or the relevant time may also have substantial influence on objects. injury and outcome. Experience with IEDs has resulted Injuries and death from vehicular damage or in substantial research and drivers for revised coding of destruction, such as decompression, intrusion injury such as the Military Combat Injury Scale. of occupant space, fire and ground impact of In military bomb, shell and missile explosions, the bombed aircraft and crash damage to cars, trucks, release of energy may be so great that death and disrup- and buses. tion from blast effects occur over a wide area. In con- trast, terrorist devices, unless they contain very large amounts of explosive, are generally of less power and the pure blast effects are far more limited. However, the locations in which such devices are often detonated may be within relatively confined spaces (e.g., subways and buses), influencing the subsequent pattern of injury caused. The energy generated by an explosion decreases rapidly as the distance from the epicentre increases. When an explosion occurs, a chemical interaction results in the generation of huge volumes of gas, which are further expanded by the great heat that is also gener- ated. This sudden generation of gas causes a compres- sion wave to sweep outwards; at the origin, this is at many times the speed of sound. Figure 9.20 Multiple abrasions and lacerations caused The pure blast effects can cause either physical frag- by flying debris projected in a bomb blast. (Courtesy of mentation or disruption of those within the immediate Professor T K Marshall, Queens University, Belfast.)  Mass disasters 145 Mass disasters Most mass disasters are now either natural disasters or terrorist and criminal events. For the non-specialist doctor at the scene of a mass disaster of any kind, the first consideration is the treatment of casualties, for which the first, and often most testing, role is on triage. Those faced with triaging patients in mass disasters are faced with a number of practical and ethical decisions. Box 9.5 illustrates the widely accepted colour-code sys- tem used to categorise disaster victims in the field. The Figure 9.21 Massive disruption of the body of an ‘expectant’ category can be the most challenging for individual who had constructed an explosive device. caregivers from an ethical and emotional standpoint. (Courtesy of Richard Jones.) In 2017, the World Medical Association (WMA) revised its Statement on Medical Ethics in the Event of Disasters. The investigation of the scene of an explosion is a The key points are summarised in Box 9.6. huge and technically complex exercise with a number The International Committee of the Red Cross and of factors to be considered, including triaging to pre- other bodies have provided advice on the appropriate serve life and evacuating casualties, whilst concurrently and dignified management of the dead which is con- attempting to establish and maintain a crime scene (or sidered to be one of the three key pillars of humani- scenes) for the identification, sampling and preserva- tarian response to disaster. The investigation of the tion of evidence. causes of death, the causes of the incident (such as a Full assessment of both the living and the dead bomb), and the identification of the dead, are specialist following an explosion is essential, with careful operations involving individuals from a wide variety of documentation of the sites and sizes of all injuries. professional backgrounds, including those with exper- Multiprofessional teams including forensic patholo- tise in the provision of emergency mortuary accom- gists, forensic physicians, forensic scientists, forensic modation, pathologists, dentists, the police and the anthropologists, forensic odontologists and crime usual state agencies responsible for sudden death; in scene investigators are required to ensure the integ- England & Wales this is the Coroner. A team of patholo- rity and proper interpretation of evidence. For the gists, assisted by police officers and mortuary staff, and deceased, post mortem radiology is essential, in order backed up by dental and radiological facilities, inspects to identify unexploded ordinance, and items com- each body and records all clothing, jewellery and per- prising components of the explosive device, which sonal belongings still attached to the bodies. The body, may assist in determining its source. Identification or body part, is then carefully examined for every aspect of deceased individuals is important, not only from a of identity, including sex, race, height, age and personal moral and ethical standpoint for families, but also to characteristics. All these details are recorded on stan- enable the relevant medicolegal authority to discharge dard forms and charts and the information is sent back their responsibilities. The identification of suicide to the identification teams, who can compare this post bombers, whose bodies are frequently extensively dis- mortem information with ante mortem information rupted following the explosion, can be extremely chal- obtained from others including relatives, friends and lenging, particularly if previously unknown to security work colleagues. A post mortem examination is usually services (Figure 9.21). performed to determine the cause of death, retrieve any Box 9.5 Triage Levels and Colour Coding to categorise disaster victims in the field Red Triage Tag (‘Immediate’ or T1 or Priority 1): Black Triage Tag (‘Expectant’ or No Priority): Patients whose lives are in immediate danger and Patients who are either dead or who have such who require immediate treatment. extensive injuries that they cannot be saved with Yellow Triage Tag (‘Delayed’ or T2 or Priority 2): the limited resources available. Patients whose lives are not in immediate danger and who will require urgent, not immediate, medi- cal care. Adapted from Kennedy K, Aghababian RV, Gans Source:  Green Triage Tag (‘Minimal’ or T3 or Priority 3): L, Lewis CP. Triage: techniques and applications in Patients with minor injuries who will eventually decision making. Ann Emerg Med 1996;28(2):136–144. require treatment. 146 Ballistic injuries Box 9.6 Recommendations from the WMA Statement on Medical Ethics in the Event of Disasters (2017) The medical profession is at the service of the patients patients compassion and respect for their dignity, and society at all times and in all circumstances. for example, by separating them from others and Therefore, the physicians should be firmly committed administering appropriate pain relief and seda- to addressing the health consequences of disasters, tives, and if possible, ask somebody to stay with without excuse or delay. the patient and not to leave him/her alone. The physician must act according to the needs The WMA reaffirms its Declaration of Montevideo of patients and the resources available. He/she on Disaster Preparedness and Medical Response should attempt to set an order of priorities for (2011) recommending the development of ade- treatment that will save the greatest number of quate training of physicians, accurate mapping of lives and restrict morbidity to a minimum. information on health system assets and advocacy towards governments to ensure planning for clini- Relation with the patients cal care. In selecting the patients who may be saved, the The WMA recalls the primary necessity to physician should consider only their medical sta- ensure the personal safety of physicians and tus and predicted response to the treatment, and other responders during the event of disasters should exclude any other consideration based on (Declaration on the Protection of Health Care non-medical criteria. Workers in situation of Violence, 2014). Physicians Survivors of a disaster are entitled to the same and other responders must have access to appro- respect as other patients, and the most appropri- priate and functional equipment, both medical ate treatment available should be administered and protective. with the patient’s consent. Furthermore, the WMA recommends the following ethical principles and procedures with regard to the Aftermath of disaster physician’s role in disaster situations: A system of triage may be necessary to deter- In the post-disaster period, the needs of survivors mine treatment priorities. Despite triage often must be considered. Many may have lost fam- leading to some of the most seriously injured ily members and may be suffering psychological receiving only symptom control such as anal- distress. The dignity of survivors and their families gesia, such systems are ethical provided they must be respected. adhere to normative standards. Demonstrating The physician must make every effort to respect care and compassion despite the need to allo- the customs, rites and religions of the patients and cate limited resources is an essential aspect of act in impartiality. triage. Ideally, triage should be entrusted to As far as possible, detailed records should be kept, authorised, experienced physicians or to physi- including details of any difficulties encountered. cian teams, assisted by a competent staff. Since Identification of patients, including the deceased, cases may evolve and thus change category, it should be recorded. is essential that the official in charge of the tri- age regularly assesses the situation. Media and other third parties Physicians should take into consideration that The following statements apply to treatment beyond in any disaster media is present. The work of emergency care: the media should be respected and facilitated It is ethical for a physician not to persist, at all as appropriate in the circumstances. If needed, costs, in treating individuals ‘beyond emergency physicians should be empowered to restrict the care’, thereby wasting scarce resources needed entrance of reporters and other media represen- elsewhere. The decision not to treat an injured tatives to the medical premises. Appropriately person on account of priorities dictated by the trained personnel should handle media relations. disaster situation cannot be considered an ethi- The physician has a duty to each patient to exer- cal or medical failure to come to the assistance of cise discretion and to seek to ensure confidential- a person in mortal danger. It is justified when it is ity when dealing with third parties. The physician intended to save the maximum number of indi- must also exercise caution and objectivity and viduals. However, the physician must show such (Continued)  Bibliography and information sources 147 Box 9.6 (Continued) Recommendations from the WMA Statement on Medical Ethics in the Event of Disasters (2017) respect the often emotional and politicised atmo- personal damages to which physicians might be sphere surrounding disaster situations. Any and all subject when working in disaster or emergency media, especially filming, must only occur with the situations. This should also include life and disabil- explicit consent of each patient who is filmed. With ity coverage for physicians who die or are harmed in regard to social media use, p ­ hysicians must adhere the line of duty. to these same standards of discretion and respect The WMA requests that governments for patient privacy. Ensure the preparedness of healthcare system to Duties of paramedical personnel serve in disaster settings. The ethical principles that apply to physicians Share all information related to public health in disaster situations should also apply to other timely and accurately. healthcare workers. Accept the participation of demonstrably quali- fied foreign physicians, where needed, without Training discrimination on the basis of factors such as The WMA recommends that disaster medicine affiliation (e.g., Red Cross, Red Crescent, ICRC, and training be included in the curricula of university other qualified organizations), race, or religion. and post-graduate courses in medicine. Give priority to the rendering of medical services over anything else that might delay necessary Responsibility treatment of patients. The WMA calls upon governments and insurance companies to cover both civil liability and any foreign objects that, for example, may be related to an Haag LC. Base deformation of full metal-jacketed rifle bullets as explosive device, and to seek any further identifying fea- a measure of impact velocity and range of fire. Am J Forensic tures, such as operation scars and prostheses. Med Pathol 2015;36(1):16–22. Karger B, Billeb E, Koops E, Brinkmann B. Autopsy features rel- evant for discrimination between suicidal and homicidal Bibliography and information gunshot injuries. Int J Legal Med 2002;116:273–278. Karger B, Bratzke H, Grass H, et al. Crossbow homicides. Int J Legal sources Med 2004;118(6):332–336. Agu CT, Orjiaku ME. Management of a nail impalement injury to Kennedy K, Aghababian RV, Gans L, Lewis CP. Triage: tech- the brain in a non-neurosurgical centre: a case report and niques and applications in decision making. Ann Emerg Med review of the literature. Int J Surg Case Rep 2016;19:115–118. 1996;28(2):136–144. Bilukha OO, Leidman EZ, Sultan AS, Jaffar Hussain S. Deaths due to Knudsen PJT. Ballistic trauma: overview and statistics. In: Payne- Intentional Explosions in Selected Governorates of Iraq from James JJ, Byard RW (eds). Encyclopedia of Forensic & Legal 2010 to 2013: prospective surveillance. Prehosp Disaster Med Medicine, 2nd ed. Elsevier; 2016. 2015;30(6):586–592. Kolomeyer AM, Shah A, Bauza AM, et al. Nail gun-induced Breitenecker R. Shotgun wound patterns. Am J Clin Pathol open-globe injuries: a 10-year retrospective review. Retina 1969;52:258–269. 2014;34(2):254–261. Dana SE, DiMaio VJM. Gunshot trauma. In: Payne-James JJ, Busuttil Krukemeyer MG, Grellner W, Gehrke G, et al. Survived crossbow A, Smock W (eds). Forensic Medicine: Clinical and Pathological injuries. Am J Forensic Med Pathol 2006;27(3):​274–276. Aspects. London: Greenwich Medical Media; 2003, 149–168. Lawnick MM, Champion HR, Gennarelli T, et al. Combat injury cod- DiMaio VJM. Bloody bodies and bloody scenes. In: DiMaio VJM. ing: a review and reconfiguration. J Trauma Acute Care Surg Gunshot Wounds: Practical Aspects of Firearms, Ballistics and 2013;75(4):573–581. Forensic Techniques, 2nd ed. Boca Raton: CRC Press; 1999, 254. Ling SN, Ong NC, North JB. Eighty-seven cases of a nail gun Fackler ML. Wound ballistics: a review of common misconcep- injury to the extremity. Emerg Med Australas 2013;25(6): tions. J Am Med Assoc 1988;259:2730–2736. 603–607. Fowler KA, Dahlberg LL, Haileyesus T, Annest JL. Firearm injuries Loder RT, Farren N. Injuries from firearms in hunting activities. in the United States. Prev Med 2015;79:5–14. Injury 2014;45(8):1207–1214. General Medical Council 2017. Confidentiality: reporting Maiden N. Ballistics reviews: mechanisms of bullet wound gunshot and knife wounds, https://www.gmc-uk.org/ trauma. Forensic Sci Med Pathol 2009;5(3):204–209. ethical-guidance/ethical-guidance-for-doctors/confidenti- Marri MZ, Bashir MZ. An epidemiology of homicidal deaths due ality---reporting-gunshot-and-knife-wounds/reporting-gun- to rifled firearms in Peshawar Pakistan. J Coll Physicians Surg shot-and-knife-wounds#paragraph-4 (Accessed 8 April 2019). Pak 2010;20(2):87–89. 148 Ballistic injuries Marshall TK. Deaths from explosive devices. Med Sci Law Thali MJ, Kneubuehl BP, Dirnhofer R, Zollinger U. The dynamic 1976;16:235–239. development of the muzzle imprint by contact shot: high- Mathews ZR, Koyfman A. Blast Injuries. J Emerg Med speed documentation utilizing the ‘skin–skull–brain model’. 2015;49(4):573–587. Forensic Sci Int 2002;127:168–173. Mehta A, Khosa F. Firearms, bullets, and wound ballistics: an Volgas DA, Stannard JP, Alonso JE. Ballistics: a primer for the sur- imaging primer. Injury 2015;46(7):1186–1196. geon. Injury 2005;36:373–379. Milroy CM, Clark JC, Carter N, et al. Air weapon fatalities. J Clin Weinberger SE, Hoyt DB, Lawrence HC, et al. Firearm-related injury Pathol 1998;51:525–529. and death in the United States: a call to action from 8 health National Archives. President John F Kennedy assassination records professional organizations and the American Bar Association. collection. https://www.archives.gov/research/jfk (Accessed 3 Ann Intern Med 2015;162(7):513–516. June 2019). Wilber CG. Medicolegal Investigation of the President John F. Payne-James JJ. Restraint techniques, injuries, and death: impact Kennedy Murder. Springfield: Charles C Thomas Publisher; rounds. In: Payne-James J, Byard RW (eds). Encyclopedia of 1978. Forensic and Legal Medicine, 2nd ed. Vol. 4. Oxford: Elsevier; Yeh DD, Schecter WP. Primary blast injuries: an updated concise 2016, 130–134. review. World J Surg 2012;36(5):966–972. PBS. Cold Case JFK. NOVA (aired 13/11/2013). https://www.www. pbs.org/wgbh/nova/video/cold-case-jfk (Accessed 3 June 2019). Further general resources Rosenfeld JV, Bell RS, Armonda R. Current concepts in penetrat- CPS. Guidance on Firearms. https://www.cps.gov.uk/legal-guid- ing and blast injury to the central nervous system. World J ance/firearms (Accessed 8 April 2019). Surg 2015;39(6):1352–1362. Firearms Act 1968. http://www.legislation.gov.uk / Santucci RA, Chang YJ. Ballistics for physicians: myths about ukpga/1968/27/contents (Accessed 8 April 2019). wound ballistics and gunshot wounds. J Urol 2004;171:1408– Police & Crime Act 2017 http://www.legislation.gov.uk/ 1414. ukpga/2017/3/part/6/crossheading/firearms/enacted Saukko P, Knight B. Gunshot and explosion deaths. In: Saukko P, (Accessed 8 April 2019). Knight B (eds). Knight’s Forensic Pathology, 4th ed. Boca Raton: International Committee of the Red Cross. Management of dead CRC Press; 2016, 241–275. bodies after disasters: a field manual for first responders. Singleton JA, Gibb IE, Bull AM, et al. Primary blast lung injury prev- https://www.icrc.org/en/publication/0880-management- alence and fatal injuries from explosions: insights from post- dead-bodies-after-disasters-field-manual-first-responders mortem computed tomographic analysis of 121 improvised (Accessed 8 April 2019). explosive device fatalities. J Trauma Acute Care Surg 2013;75(2 World Medical Association. WMA statement on medical ethics in Suppl 2):S269–S274. the event of disasters. https://www.wma.net/policies-post/ Smith S. Voluntary acts after a gunshot wound of the brain. Police wma-statement-on-medical-ethics-in-the-event-of-disas- J 1943;16:108–110. ters/ (Accessed 8 April 2019). Thali MJ, Kneubuehl BP, Zollinger U, Dirnhofer R. A study of the morphology of gunshot entrance wounds, in connection with their dynamic creation, utilising the ‘skin–skull–brain’ model. Forensic Sci Int 2002;125:190–194. 14 Identification of the living and the dead ▪▪ Introduction ▪▪ Age estimation in the living ▪▪ Methods of identification ▪▪ Bibliography and information sources ▪▪ Identity of decomposed or skeletalised remains ▪▪ Further general resources ▪▪ Mass disasters Introduction individuals have no records with them, and the estima- tion is required to determine, for example, if they have Loss of identity and proof of identity is a common prob- achieved the age of criminal responsibility in the rel- lem in the medicolegal setting. Such loss of identity evant jurisdiction or if are they classed by age as chil- might be deliberate, for example, if someone wishes to dren, in which case different legal principles may apply conceal their own identity or that of another for criminal to their situation. Estimation of age is simpler in children or other personal reasons, or it might be unintentional, and young people where developmental milestones may for example, due to natural disaster (e.g., tsunami, wild- be relevant and is more difficult and far less precise in fire, volcanic eruption) or terrorist or accidental events mature adults. However, recent advances in DNA analy- (e.g., 9/11). Individuals (themselves or relatives) or legal sis and in particular the recognition that the epigenetic and national authorities may require that identity to be signature of DNA methylation changes during an indi- established. This may apply to living or deceased indi- vidual’s lifespan means that DNA methylation age-cor- viduals. related changes have the potential to act as a (relatively) Formal, correct identification of a body is a key ques- accurate means of age estimation. tion to be answered when a body is found in any medi- There are additional means of identification such as colegal investigation of death. In England & Wales, it fingerprint or DNA databases, but these will only be of represents the first question to be answered at the relevance where the databases are well established and Coroner’s inquest. Often visual identification by an where the individual has been convicted of, or is being appropriate person may not be possible due to factors investigated for criminal offences. For these reasons, the such as facial trauma, decomposition, loss of body parts person or body with no previous criminal record may or deliberate mutilation and other techniques must be prove to be more difficult to identify than those with such employed to confirm identity. a record with, or exposure to, a justice system. The pro- All governments require systems to be in place for liferation of genealogical databases has however created the rapid implementation of mass disaster responses an additional potential source of DNA profiles that can in situations of multiple deaths so that casualties and be accessed by police and other bodies, and is likely to deceased can be identified expeditiously. This is for result in complex human and civil rights concerns over legal process, reassurance and support for relatives of the coming years. the injured and deceased. Assessment of the deceased to establish identity is a specialised task for a multiprofessional team which Methods of identification may include forensic pathologists, forensic odontolo- gists, forensic anthropologists, forensic physicians and Identification criteria radiologists. Their work will be often set in challenging Identification criteria used are referred to as primary or and difficult conditions, in the midst of humanitarian secondary. Primary identification criteria are 1) finger- work and investigations for possible criminal cases. All prints, 2) DNA, and 3) dental. those working in the forensic setting should be aware of It must be recognised that in recent years the speci- the general principles to establish identity in the living ficity of some aspects of fingerprint and dental assess- and deceased. ments have been brought into question. Secondary This same group of practitioners may be called criteria include features such as unique medical char- upon (individually or together) to assist in establishing acteristics, deformity, marks and scars, radiological a person’s age. The two main settings where this may evidence, personal effects and distinctive clothing. be relevant is in criminal cases and asylum applica- Examples of other features that may also provide tions. Reasons to know age are manifold, and frequently some assistance in identification include clothing,  Methods of identification 199 photographs and location. Additional techniques such elements of forensic science) that the use of DNA should as gait analysis or facial profiling from CCTV can be use- be considered as another piece of the jigsaw in the over- ful when other features cannot be used, although their all puzzle of solving crime and identifying unknown accuracy is less consistent. individuals. Comparison of DNA profiles with assumed or known family members or against known databases can ensure DNA profiling a person’s identity is established. If these comparisons The specificity of individual DNA profiles means that cannot be done, other tests must be used. from a statistical point of view it can be considered spe- As forensic DNA analysis continues to progress, cific to any given individual. identifying, extracting and amplifying smaller and The molecule of DNA has two strands of sugar and smaller amounts of genetic material, so the risks of phosphate molecules that are linked by combinations contamination from other sources increase. Crime of four bases, adenine, thymine, cytosine and gua- and mass disaster scenes have great potential for cross nine, forming a double helix structure. Only about 10 contamination and standard operating procedures to per cent of the molecule is used for genetic coding (the avoid contamination must always be in place to mini- active genes), the remainder being ‘silent’. In these mise this risk. Appropriate protective clothing must be silent zones, there are between 200 and 14,000 repeats worn to prevent the investigators obscuring any rel- of identical sequences of the four bases. Sir Alec Jeffreys evant DNA by their own material being inadvertently found that adjacent sequences were constant for a shed from exposed skin, or by sneezing, or perhaps given individual and that they were transmitted, like even by touching. In many jurisdictions, it is now a blood groups, from the DNA of each parent. The statis- requirement for all those involved in the identification, tical analysis of DNA identification is extremely com- collection and analysis of samples to provide exclusion plex and it is important that any calculations are based DNA samples in the same way as exclusion fingerprints upon the DNA characteristics of a relevant population were once provided. and not upon the characteristics of a ‘standard’ popu- lation somewhere else in the world. Forensic genetics Examination of dental structures developed from protein-based techniques and brought Forensic odontology is one of the most important with it the term ‘DNA fingerprinting’, this being based specialties available to establish or confirm identity on restriction fragment length polymorphisms (RFLPs) of unknown bodies whether in isolation, after terror- of high-­molecular-weight DNA. Development of ana- ist events, in mass graves or after natural disasters. lytical techniques resulted such as the amplification The success of such identification is very dependent of much smaller short tandem repeat (STR) sequences on access to ante mortem records from general den- using the polymerase chain reaction (PCR) which soon tal practitioners. Pre-existing (ante mortem) dental replaced RFLP analysis and became standard in genetic records and charts and radiographic images can be identification. STR multiplexes are now available which compared with examination of the dentition of the simultaneously amplify up to 30 STR loci from as little as deceased (Figure 14.1). If these are not immediately 15 cells or fewer. The huge volume of information asso- available an odontologist will construct dental charts ciated with the great range of observed STR genotypes of bodies whose identity remains unknown or uncon- allows for genetic individualisation (with the exception firmed despite a police investigation, so that, should of identical twins). dental information become available at a later date, Unlike before, there is now no need to match blood the two sets of records may be then be compared. The with blood, and semen with semen, as all the DNA in essence of the identification by dentition is compari- one individual’s body must of necessity be identical. son. This implies that the dental chart has to be com- Buccal swabbing permits simple sampling of a sus- pared with, and found to match, a chart whose origins pect. A suspect in any crime leaving cells or biological are known (Figure 14.2). Unfortunately, studies suggest fluids at a scene leaves proof of their presence at the that the recording of accurate dental charts by general scene. The continued ability to analyse smaller and dental practitioners is sometimes inadequate. smaller amounts of DNA and to recover and analyse The forensic odontologist is of