1. By: Mesfin Tafa(MPH).
Department of Public Health
Mizan Tepi University
Mizan-Teferi, 2014
6/15/20151

2. Objectives
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At the end of this session you will able;
 To know, screen/manage victims of some
medico-legal cases.

3. Points to be considered in Medico legal
case
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Records: complete and always have a carbon copy
Dates and times of observations must be noted
accurately –avoid forgetfulness after along time.
Include;
A. Identifications :Who identified the body and how
unidentified bodies are better numbered.
B. Authority: Instructions from police or lawyer

4. 6/15/20154
C. Information: When and where the body was
found ;If alive when admitted to medical care, clinical
information available.
C. External examinations
By photo graph or simple sketches the exact
position of the body, the way it is lying.
Don't touch them, they are police material.
C. Internal Examination :Blood sample, Tissue
sample

5. Some examples
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 Rape/sexual violence
Strangulations
Poisoning
Neonatal deaths / Infanticide/,Still birth
Abortions
Gun-shot wounds

6. 6/15/20156

7. 6/15/20157
Sexual violence-“Any sexual act, attempt to obtain
a sexual act, unwanted sexual comments or
advances, or acts to traffic, or otherwise directed,
against a person's sexuality using coercion, by any
person regardless of their relationship to the victim,
in any setting, including but not limited to home and
work”. (WHO,2002)

8. 6/15/20158
Rape- “Physically forced or otherwise coerced
penetration, without consent – even if slight of
the (oral/vaginal/anal), using a penis, other
body parts or an object.”(WHO, 2002).

9. Intro…
6/15/20159
 Most Underreported crime. But;
 The reported rape rate -USA -4x higher
than that of Germany, 13x higher than
Britain’s, and 20x higher than Japan’s.
 Determining true rape rates is extremely
difficult, and comparing international rape
rates is difficult.
 More fertile women are more at risk than
less fertile.

10. Intro…
6/15/201510
 Rape is not limited to human societies
and many animal show evidence of
sexually coercive techniques.
 Various theoretical viewpoints have
struggled to identify the causes of rape,
as well as effective plans for preventing
sexual assaults and treating victims.

11. Theories of Rape
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Four main theories
 Feminist
 Social learning
 Evolutionary
 Biosocial/synthetic

12. Feminist Theory of Rape
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 Rape is motivated by power not sexual desire.
 Males are indirectly socialized to rape via gender
role messages asserting male authority and
dominance over women.
 Rape “is nothing more or less than a conscious
process of intimidation by which all men keep all
women in a state of fear.”
Size disparity and women’s weaker physical strength
makes them further vulnerable to sexual coercion.

13. Social Learning Theory of Rape
6/15/201513
 Social learning places less emphasis on sexual
politics and is generally agnostic about what the
ultimate purpose of rape is.
 Social learning theorists agree with feminists
that the negative images of women as the
sexual playthings of men promulgated in
advertising and pornography play a critical
role in the rape causation.
 Social learning theory attempts to explain rape
at the individual level.

14. Evolutionary Theory of Rape
6/15/201514
 Holds the view that coercive sexuality is a normal
male strategy designed by natural selection and
adaptation.
 Forced copulation is observed in many animal
species and that the key is to understanding rape
is the wide disparity in parental investment
between the sexes.
 All men are potential rapists & men who employ
coercive tactics do so because of environmental
factors.

15. Biosocial(Synthesized)Theory of
Rape
6/15/201515
 The sex drive and the drive to possess and control
motivates rape.
 The average sex drive of men is stronger than
women.
 Although the motivation for rape is unlearned, the
specific behavior surrounding it is learned.
 Because of the neurohormonal factors, people will
differ in the strength of their sex drives and in their
sensitivity to threats of punishment.

16. 6/15/201516
 Biosocial theory of rape also predicts that
rape behavior is not exhibited exclusively by
males; a small amount of rapes should be
committed by women.

17. 6/15/201517
 High risk groups
 Prostitutes
 Military
 Homeless and runaways
“High Risk” Perpetrators(Rapist)
Male college athletes
Fraternity members
Men with restraining orders

18. Consequence of rape
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Physical injuries: Broken bones and teeth,
burns,abrasions(graze),lacerations,contusions
, etc
 STIs including HIV
25% chance of acquiring STD
 Gonococci = 6 - 12%
 Chlamydia = 4 - 17%
 Syphilis = 0.5 - 3%
 1 -2/1,000 odds of acquiring HIV

19. Consequences of rape---
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Psychological consequences
-Depression
- Post traumatic stress disorder(PSTD)
- Psychosomatic complaints
- Sexual dysfunctional disorder
- Suicide

20. Consequences of rape---
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Social consequences
- Marital/relationship problems
- Reduced self-realisation /self-esteem
- Stigma
Unwanted pregnancy
-5% chance of pregnancy

21. Management of Rape Victims
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1. History
 Age/date of birth of the patient
 Location, date and time of assault
 Circumstances of assault – identity and number of
assailants
 Type of physical restraints used (weapon, drugs,
alcohol)
 Details of sexual contact – actual or attempted
penetration (penile, digital or object), route of
penetration (vaginal, oral, anal), ejaculation (and
sites), urination, use of condom and lubricants

22. History…
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Activities of the patient after the assault
(shower/bath, change of clothing, douching, use
of tampon, urination, defecation)
– these may destroy the evidence.
 Details of any symptoms occurring after the
assault (genital bleeding, discharge, itch, sores
or pain; urinary symptoms; anal pain or
bleeding; abdominal pain)

23. History…
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 Pertinent medical history – allergies, disease profile,
disability
 Sexual/reproductive health history in teenagers and
adults.
 LNMP(date, days, cycle and regularity),contraceptive
use (method and date of last dose/injection), last
consensual sexual encounter and pelvic surgery.

24. 2. Physical examinations(head to toe)
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Collection of clothing-tear, stain
Emotional status (e.g. controlled, fearful,
listless, tense, sobbing etc.)
External evaluation
abrasions, lacerations, bruise, bite marks
Oral cavity
secretions, injuries

25. Physical exam…
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Genitalia
-hair sampling, vaginal secretions
-Injuries: Posterior fourchette is the most
common site of injury. Labia majora and minora is
2nd most common genital injury.
-Hymen-If virgin
Nb. Avoid digital vaginal exam(virgin)
Anus and Rectum
-injuries
Nb. An absence of physical injuries does not mean that
rape/sexual violence did not occur.

26. 3. Investigations
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A. Evidence on patient’s body
-Fingernails
-Saliva on skin
-Semen or other stains on body
-Head hair
-Pubic hair

27. Investigations….
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B. Ano-rectal swabs
Done before the genital region .
Swab the anal area and then rectum
C. Genital specimens
External genital swab
Deep vaginal swabs
Cervical swabs
Penile swabs?

28. Investigations….
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D. HIV Test
E. Urine for pregnancy test
F. Hepatitis screening
G. Reference DNA specimen
H. Drugs and alcohol
I. Urine for drugs screen

29. 4.Treatment and prophylaxis
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Physical injuries: TT , Analgesics, Antibiotics
Antiemetic
STD Prophylaxis based on guidelines
HIV prophylaxis( AZT/3TC) – If not +ve test
result
Pregnancy Prophylaxis –if not pregnant
-Emergency Oral Contraceptive Pills (EOCP)
(2 doses must be taken 12 hrs apart and within 5 days)
-Copper IUCD , Regular OCP,
Hepatitis B Virus vaccine

30. Treatment…
6/15/201530
Ensure Victim’s Safety-
Psychological support
 Social worker involvement
 Safe place to go
 Restraining order
 Phone numbers of shelters

31. Article 620.- Rape
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1. Whoever compels a woman to submit to
sexual intercourse outside wedlock, whether by
the use of violence or grave intimidation, or
after having rendered her unconscious or
incapable of resistance, is punishable with
rigorous imprisonment 5-15 years.

32. 6/15/201532
2. Where the crime is committed:
a) on a young woman between 13 and 18
years of age; or
b) on an inmate of an alms-house or asylum or
any establishment of health, education,
correction, detention or internment w/c is under
the direction, supervision or authority of the
accused person, or on anyone who is under the
supervision or control of or dependent upon
him; or

33. 6/15/201533
c) on a woman incapable of understanding
the nature or consequences of the act, or of
resisting the act, due to old age, physical or
mental illness, depression or any other
reason; or
d) by a number of men acting in concert, or
by subjecting the victim to act of cruelty or
sadism, the punishment shall be rigorous
imprisonment from 5-20 years.

34. 6/15/201534
3 .Where the rape has caused grave
physical or mental injury or death, the
punishment shall be life imprisonment.
4.Where the rape is related to illegal restraint
or abduction of the victim, or where
communicable disease has been transmitted to
her, the relevant provisions of this Code shall
apply concurrently.

35. 6/15/201535

36. Strangulation Vs “Chocking”
Strangulation- is a form of asphyxia
characterized by closure of the blood vessels and
air passages of the neck as a result of external
pressure on the neck.
Choking - an internal obstruction of the
airway(Trachea) partly or entirely by a foreign
object (i.e. food)

37. Types of strangulations
 Hanging-Suspension from a cord wound
around the neck
 Manual(Throttling)- (most common) -
Strangulation using the fingers or other
extremity-mostly men on women
 Ligature(Garroting)-Strangulation
without suspension using some form of
cord-like object.

38. 6/15/201538

39. Vessel and Tracheal occlusions
 Carotid artery :Anterior neck
Most common, 11 pounds of pressure for 10
seconds, unconsciousness, but regained in
10 seconds if pressure released
 Jugular vein :Lateral neck
2nd most common, 4.4 pounds of
pressure completely obstructs
 Tracheal: Usually minor, (if any) results
death .
≥33 pound of pressure, fracture.

40. Fatality
 Death will occur in 4-5 minutes if strangulation persists
Cause for immediate death
a. Cardiac arrhythmia provoked by pressure on the
carotid artery nerve ganglion causing cardiac arrest
b. Pressure obstruction of the carotid arteries
prevents blood flow to the brain
c. Pressure on the jugular veins prevents venous
blood flow from the brain, backing up blood in the
brain and leading to unconsciousness, depressed
respirations and asphyxia
d. Pressure obstruction of larynx cuts off air flow,
producing asphyxia

41. Causes of strangulations
 Assault ( physical, verbal, sexual(rape))
 Depression
 Other causes (autoerotic strangulation
What other causes you know??

42. Physical examinations
 Abrasions, lacerations, contusions, or edema
to the neck, depending on how the patient
was strangled
 Subconjunctival and skin petechiae cephalad
to the site of choking (Tardieu spots)
 Severe pain on gentle palpation of the
larynx, which may indicate laryngeal/
hyoid fracture

43. Physical exam…
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 Mild cough
 Stridor
 Muffled voice
 Respiratory distress
 Hypoxia (usually a late finding)
 Mental status changes

44. Management
 Aggressive management despite initial
neurologic findings:
Neck stabilization
Radiologic imaging
Intubation and mechanical ventilation
Treatment of possible increased ICP.

45. Management---
6/15/201545
 Determine mechanism
 Poor prognostic indicators:
absent respirations
absent pulse
requirement for immediate
intubation
pH<7.2.

46. Management---

47. Poisoning

48. Poison
 A poison is any substance that can harm
the body.
 “All things are poison and nothing is without
poison, only the dose permits something
not to be poisonous.”
Common Poisons
 Medications, Petroleum products, Cosmetics
 Pesticides, Plants, Food

49. Effects of a Poison
 Harm to body based on nature of poison,
concentration, route of entry, patient’s age
and health
 Damage to skin and tissues from contact
 Suffocation
 Localized or systemic damage to body
systems

50. Classification of Poisons
 Ingested
 Inhaled
 Absorbed
 Injected

51. Ingested Poison
 Child: may accidentally eat or drink a toxic
substance.
 Adult: Often an accidental or deliberate
medication overdose.

52. Assessment: Ingested Poisons
 What substance was involved?
Look for container; check labels
Transport with patient to hospital
 When did exposure occur?
Quick-acting poison requires faster
treatment
ER personnel need to know for appropriate
testing and treatment

53. Assessment ---
 How much was ingested?
Estimate missing pills by looking at
prescription label
 Over how long a time?
Treatments may vary
Was medication taken for very first time?
Was medication being taken chronically?

54. Assessment ---
 What interventions have been taken?
Treatments indicated on label,
Other home remedies (syrup of ipecac)
 What is patient’s weight?
Rate of onset of toxic effects is related to
weight

55. Assessment ---
 What effects has patient experienced?
Nausea, vomiting, altered mental status,
abdominal pain, diarrhea, chemical burns
around mouth, unusual breath odors

56. Food Poisoning
 Can be caused by improperly handled or
prepared food
 Symptoms: nausea, vomiting, abdominal
cramps, diarrhea, fever
 May occur within hours of ingestion, or a day
or two later

57. Cause of food poisoning
 Chemical food poisoning: heavy metals
(Pb, , zn, cu, and mercury), pesticides,
herbicides, fertilizers.
 Poisonous plant tissues: e.g. Poison
Mushroom
 Poisonous animal tissues: non edible fish
 Microbial intoxication:
Botulism(Cl.botulism), Cl.
Perfferinges, S. Aurous

59. -143 cases & 9 deaths 2008
in AA because of
adulteration of food oil.

60. 6/15/201560

61. 6/15/201561

62. Treatment: Food Poisoning
 Activated Charcoal
 Antidotes

63. Inhaled Poisons
 Common types
Carbon monoxide
Ammonia
Chlorine
Agricultural chemicals and pesticides
Carbon dioxide

64. Signs and Symptoms: Inhaled
Poisons
 Difficulty breathing
 Chest pain
 Coughing
 Hoarseness
 Headache, confusion, altered mental status
 Seizures

65. Assessment: Inhaled Poisons
 What substance is involved (exact name)?
 When did exposure occur?
 Over how long did exposure occur?
 What interventions has anyone taken?
 Remove patient?
 Ventilate area?
 What effects is patient experiencing?

66. Treatment: Inhaled Poisons
 Move patient from unsafe environment
using trained and equipped personnel
 Open airway; provide high flow oxygen
 History, physical exam, vital signs
 Transport with all containers, bottles, and
labels
 Ongoing assessment en route

67. Carbon Monoxide (CO)
Poisoning
 Colorless, odorless, tasteless gas created
by combustion.
 Can be caused by improper venting of
fireplaces, portable heaters, generators.
 Common cause of death during winter
(Summer…in ETH) and power outages.

68. Signs and Symptoms: CO
Poisoning
 Headache (band around head)
 Dizziness/nausea
 Breathing difficulty
 Cyanosis
 May be multiple patients with similar
symptoms in confined area together

69. Treatment: CO Poisoning
 High flow oxygen is appropriate treatment,
but CO bonds to red blood cells much more
strongly than oxygen does.
 Can take several hours or days to “wash” CO
from bloodstream.

70. Hydrocarbons
6/15/201570
 Kerosene ingestion:
 Risk of aspiration
 GIT & Respiratory effects.
 Burning sensation, nausea, belching and diarrhea
 Cough, chocking, gagging and grunting.
 CXR 2-8 hrs later: Pulmonary infiltrates or
perihilar densities.
 pneumatoceles, pleural effusion or pneumothorax
and bacterial super-infection
 Resolution 2-7 days.

71. 6/15/201571
Treatment:
Do not induce vomiting
Do not attempt gastric lavage
Risk of aspiration outweighs any benefit
from removal of substance
CXR around 2-4 hrs “not before 2hrs”
Observe in ER for 6-8 hrs if no symptoms
 discharge.

72. Alcohol and Substance Abuse
 Abuse of alcohol and other drugs crosses
all geographic and economic boundaries.
 Potent drug affects central nervous system
 Can be addictive
 Emergencies may result from recent
consumption or years of abuse
 Treat patients as any others
 Abuse can lead to or worsen other medical
conditions

73. Alcohol Abuse
 Alcohol often consumed with other drugs, which
can result in a serious medical emergency
 Impaired patients can be uncooperative or
combative
 Contact law enforcement if safety concern

74. Assessment: Alcohol Abuse
 Many medical conditions mimic alcohol
intoxication
 Intoxicated patients may also have medical
problems
 All patients receive full assessment regardless of
suspicion of intoxication

75. Signs and Symptoms: Alcohol Abuse
 Alcohol odor on breath
 Unsteady on feet
 Slurred, rambling speech
 Flushed, complaining of being warm
 Nausea/vomiting
 Poor coordination
 Blurred vision
 Confusion/altered mental status

76. Alcohol Withdrawal
 Abrupt cessation of drinking may cause some
alcoholics to suffer from delirium tremens (DTs)
 Can be serious, resulting in tremors,
hallucinations, and seizures

77. Signs and Symptoms: Alcohol
Withdrawal
 Confusion and restlessness
 Unusual behavior, demonstrating “insane”
behavior
 Hallucinations, gross tremor of hands, profuse
sweating
 Seizures

78. Patient Care: Alcohol Abuse
 Vomiting common; standard precautions are
essential
 Keep suction ready
 Stay alert for airway and respiratory problems
 Monitor vital signs
 Gather history from patient, bystanders
 Stay alert for seizures

79. 6/15/201579
 Infanticide is defined as the killing of a child
under the age of 1.
Infanticide

80. Who is murdered?
6/15/201580
Based on studies by Daly and Wilson (1984),
and Minturn and Stashak (1982), the most
frequent killed infants are:
 Illegitimate children (53-57%)
 Weak of deformed children (53-50%)
 Twins and triplets (40%)
 Due to family size or circumstances of birth
spacing (23-31%).
 Females> males???

81. Suicide
6/15/201581
 The intentional ending of one’s own life
 Every year, over 800,000 people die from suicide;
this roughly corresponds to one death every 40
seconds.

82. 82
Myths and Facts about suicide
People who talk about suicide don't complete
suicide.
 Many people who die by suicide have given
definite warnings to family and friends of their
intentions. Always take any comment about suicide
seriously.
 Suicide happens without warning.
Most suicidal people give clues and signs regarding
their suicidal intentions

83. 83
Suicidal people are fully intent on dying.
Men are more likely to be suicidal.
Men are 4X more likely to kill themselves than
women.
Women attempt suicide 3X more often than men
do.
Asking a depressed person about suicide will push
him/her to complete suicide.
Studies have shown that patients with depression
have these ideas and talking about them does not
increase the risk of them taking their own life.

84. 84
Improvement following a suicide attempt or crisis
means that the risk is over.
Most suicides occur within days or weeks of
"improvement," when the individual has the
energy and motivation to actually follow through
with his/her suicidal thoughts.
The highest suicide rates are immediately after a
hospitalization for a suicide attempt.

85. 85
Once a person attempts suicide, the pain and
shame they experience afterward will keep them
from trying again.
The most common psychiatric illness that ends in
suicide is Major Depression, a recurring illness.
Every time a patient gets depressed, the risk of
suicide returns.
Sometimes a bad event can push a person to
complete suicide.
Suicide results from having a serious
psychiatric disorder. A single event may just
be “the last straw.”

86. 86
Suicide occurs in great numbers around holidays
in November and December.
Highest rates of suicide are in May or June, while
the lowest rates are in December.

87. 87
Risk Factors
 Psychiatric disorders
 Past suicide attempts
 Symptom risk factors
 Sociodemographic risk factors
 Environmental risk factors

88. 88
Most common psychiatric risk factors resulting
in suicide:
 Depression*
 Major Depression
 Bipolar Depression
 Alcohol abuse and dependence
 Drug abuse and dependence
 Schizophrenia
*Especially when combined with alcohol and drug
abuse
Psychiatric Disorders

89. 89
Other psychiatric risk factors with potential to result in
suicide (account for significantly fewer suicides than
Depression):
 Post Traumatic Stress Disorder (PTSD)
 Eating disorders
 Borderline personality disorder
 Antisocial personality disorder

90. 90
Past suicide attempt
 After a suicide attempt that is seen about 1% per
year take their own life, up to approximately 10%
within 10 years.
 More recent research followed attempters for 22
years and saw 7% die by suicide.

91. 91
Symptom Risk Factors During Depressive
Episode:
 Desperation
 Hopelessness
 Anxiety/psychic anxiety/panic attacks
 Aggressive or impulsive personality
 Has made preparations for a potentially serious
suicide attempt or has rehearsed a plan during
a previous episode
 Recent hospitalization for depression
 Psychotic symptoms (especially in hospitalized
depression)

92. 92
Symptom Risk Factors …..
 Major physical illness, especially recent
 Chronic physical pain
 History of childhood trauma or abuse, or of being
bullied
 Family history of death by suicide
 Drinking/Drug use
 Being a smoker

93. 93
Sociodemographic Risk Factors
 Male
 Over age 45 - 64
 White
 Separated, widowed or divorced
 Living alone
 Being unemployed or retired
 Occupation: health-related occupations higher
(dentists, doctors, nurses, social workers)
 especially high in women physicians

94. 94
Environmental Risk Factors
Easy access to lethal means
Local clusters of suicide that have a
"contagious influence"

95. 6/15/201595