The Clinical Forensic Evaluation of GSWs: What the Tactical Medic Needs to Know

- [Instructor] So if you would, everybody, if you will make sure and put yourself on mute, that will help us with the background noise. And there are several options to either ask questions or have comments. You can raise your hand using the option. At the bottom of the page there's a tab where you can raise your hand. You can put comments in the chat box. And we'll make sure and pass those on to the speaker. And then I'm sure there'll be a spot at the end or maybe during the presentation for a Q and A session. So again, if you would, make sure that you're on mute. And then when you finish your question, go back on mute so we don't have any background noise, which can interrupt the presentation. And with that, although this one is eligible for CME, I believe, right, Deanna, and we should have, there'll be a link for our, there's a disclosure for learners regarding any interest conflicts and all the CME requirements.

- And there's a handout.

- And a handout. Yes, thank you. It does take a little bit of time for your CME records to show up in the track CME program that ACEP has. So you might allow a week or 10 days before it shows up at the earliest. So it will be there, it just takes some time for it to go through the process. With that, Dr. Springer, I will turn it back to you.

- Excellent, thank you everybody. And I'm really excited to introduce our speaker this evening. Dr. Bill Smock is the police surgeon and directs the clinical forensic medicine program for the Louisville Metro Police Department in Louisville, Kentucky. In 1994, he became the first physician in the United States to complete a postgraduate fellowship in clinical forensic medicine with the Kentucky Medical Examiner's office. Dr. Smock is currently a clinical professor of emergency medicine at the University of Louisville School of Medicine and the medical director of the San Diego-based Training Institute on strangulation Prevention. Dr. Smock.

- Brian, thank you. I just got a text from John, and I wanted to thank the section and John for this, it just arrived in the mail today, the award that you all gave last October at Scientific Assembly. Thank you, I am humbled, because this has been a long journey. Actually, I was thinking back, I took my CONTOMS course as a third year resident 30 years ago, when my heroes were Josh Fehr, Dave Razimov, Rich Carmona. Dave is no longer with us, but Rich, my hero, mentor and dear friend. So there are those that when we first start out in tactical medicine, we look up to. And there, when I looked at the list of people who are here, we even have, we have paramedics, we have EMS fellows, those that are just starting their career in TEMS. So please reach out to those that are a little older. As Brian said, not that he was calling me old, but it has been 30 years since CONTOMS. What I want to share with you is something that I share with my residents, and some of you have heard this, and that is the forensic evaluation of gunshot wounds. How do we look at a wound, what do we document? How do we describe, how do we interpret, how do we know when our patients are telling us the truth or not telling us the truth? And what are the benefits of knowing when a patient is telling us the truth or not telling us the truth? The handout that's available to you is a guide that I created for my officers, and two of my medical students helped me create this document. I've sent this out to every officer of my 1,100 officers I have on LMPD. And it gives information of how to look at a wound, understand the physical characteristics associated with that wound. There's also information in here, there are copies of our blank search warrants that we use for living forensic exams. The concept of clinical forensic medicine is to take that same science and knowledge base that the forensic pathologist uses daily, but apply it to those living patients that present in the emergency department. And so I have spent my career, it's the last 30 years, educating doctors, nurses, police officers, prosecutors in how to apply the forensics of pathology to our living patient. So in this handout I think you'll find it very beneficial. Feel free to download it, share it with your residents, your fellows, your paramedics. Because in there are actual photographs and some of which you will see tonight. So if you're welcome to duplicate that, you have my permission to do so. So this concept of clinical forensic medicine. I'm taking that same science the forensic pathologists use, but apply to that living patient that presents to us everyday in the emergency department. Because the question is who will deal with those forensic issues? Who will answer those questions? So when the police come to the attending ER doc, to the resident, to the fellow, and they say, doc, what does this wound mean? How do you interpret this wound? Is this consistent or inconsistent with the history that we've been given by a witness, by a police officer, by a potential suspect? So this is the concept of living forensic medicine. We're gonna talk specifically about gunshot wounds. So in your hospitals, and Brian, if you can be watching the chat, I'm curious, do any of the hospitals where you practice have a living forensic medicine program? There is a model in the level one trauma center in Christiana, in Delaware, where the hospital pays for a forensic nurse in the ER 24-7. And that is paid for by the hospital because the surgeons and the ER docs wanted it to keep their ass out of going to court. And when I asked physicians, well, why don't you document the physical characteristics, or why don't you interpret certain things, they say, I don't want to go to court. And that makes perfect sense. No one wants to spend uncompensated time outside of the hospital. However, I think our patients may suffer if we elect to only put wound one and wound two in the chart. This is the press release from the Department of Justice recognizing the ER at Christiana Healthcare in Wilmington by having that forensic nurse in the ER 24-7. The prosecutors love it. The police departments love it, because when that detective walks into the ER, they're handed a disk with all the photographs of every wound, they're handed a diagram, they're handed the evidence, the clothing in separate paper bags, not cross-contaminated, all thrown into a plastic bag, but labeled with the patient's name, their chart number, their medical record number. And it's what is really the benefit to the criminal justice system by having that information collected in a way that can be used in court versus then compromising the evidence in the emergency department. In my career, I've probably been involved in more than 100 officer-involved shootings. And this is one, this is Peter Rignon, one of my officers who took three fatal rounds to his head and neck. And my role as the police surgeon is to tell the family, in this case his wife Rebecca, that we couldn't save him. And officers, particularly where we find ourselves now, do not want to be involved in any sort of shooting. And what is interesting, and this relates to stranglers, every one of these officers had one thing in common. They were shot by a strangler. And we're gonna talk about, I think in our next webinar, we're gonna talk about strangulation from a forensic standpoint. But when we look at this data, more than 70% of officers who are killed in the line of duty, shot in the line of duty, are shot by stranglers. And so that is the number one key when we're trying to predict who will get shot and who will shoot you the police officer, it's going to be a strangler. And if you look close enough, it's there somewhere in his background. We found ourselves in this post-Ferguson, post-George Floyd, post-Breonna Taylor. And having been involved either directly or indirectly with all of these three cases, I can tell you this is not a good time to be involved in a shooting. And I will share with you what is at risk and I'll share you some of the information from my shootings involving my officers where deadly force would've been appropriate, but they elected not to because they said they didn't want to end up on the front page of the paper. So when we have an officer-involved shooting, whether it's they had a traffic stop, whether it's a SWAT operation, what's the risk? Well for the officer, their career, reputation, the possibility of criminal charges and civil liability. For the agency, reputation, credibility and civil liability. And then for local government, the liability. But now we're seeing civil unrest as a consequence of even of a justified officer-involved shooting. This is one of my officers and this was, it worked out well, but it may not have. We have a fleeing suspect who is armed with a pistol in his hand. You can see this in this body camera. The officer has his weapon drawn at the officer, and over on the left side of the screen we have another officer with his weapon drawn. Now this suspect points, as you can see, points his weapon at the officer. That would be justification for deadly force. But what does the officer do on the left? He elects to tackle a suspect with a loaded handgun. It worked out well, but it might not have. And when I asked the officer why he tackled him rather than shooting, he said I didn't want to end up on the front page of the paper. Well, you could have ended up on the front page of the paper as a casualty being shot by a suspect who, clearly from a legal standpoint, you could have used deadly force. But we have officers clearly not wanting to use deadly force even though it would've been appropriate. When it comes to the forensic evaluation of officer-involved shootings, at least here for LMPD, we have two kind of distinctions. If the officer is dead at the scene, either the officer kills a suspect, suspect kills an officer, or an officer kills an officer, and they're dead at the scene, then that is the purview of the medical examiner's office. Where my team comes in is if we have a non-fatal officer-involved shooting, whether an officer wounds a suspect, suspect wounds an officer, officer wounds himself, officer wounds an officer, or an officer fakes a shooting. This is where the clinical forensic portion of my role as the police surgeon comes in. When we look at what IACP has put out there, look, this is from I think 2019, they ask the question to the investigating agency were the injuries consistent with the incident as described by the involved officers, okay. Who in a non-fatal officer-involved shooting or any shooting is going to perform that forensic evaluation and make that determination are the injuries consistent or inconsistent. And as the tactical medic if you are involved in a shooting on an operation, this may fall to you. So we're gonna talk about, here's one of my cases, Breonna Taylor. These are high dollar cases, and my city paid out 12 million to settle this case. In the center of the screen is Sergeant John Mattingly. Sergeant Mattingly was shot as he entered the door, our fatal funnel. He was the first officer through that door and he was shot by Breonna Taylor's boyfriend. He took a round to his left thigh, got a superficial femoral. The fellow officers, and because this was not a SWAT operation, we did three other warrants that night, that this is, narcotics actually served a fourth warrant, and they had no tactical medic with them. So a fellow officer applied a tourniquet and then we transported Sergeant Mattingly to our resuscitation room. And that's where I first encountered him and documented his wounds. Now we know that even though it's a justified shoot, someone shoots you as you're making entry, you returned fire. In this case, the individual that discharged and shot Sergeant Mattingly was not injured, but Breonna Taylor was. And look what the plaintiff's attorney, representing Mr. Walker, who is Brianna's boyfriend, said. We think it is much more likely that one of the 30 to 45 shots fired by LMPD is what struck Officer Mattingly. So what the plaintiff's attorney is saying is no, his client did not shoot Officer Mattingly. He was shot by a fellow officer. Okay, well what does the physical evidence show? How will you render that determination in that nonfatal shooting? Luckily John did not die, but he did sustain that injury to the superficial femoral, which required surgical intervention. So who's gonna make that determination? Who on your team, if this were a tactical operation, who in your community is going to evaluate the non-fatal forensic issues related to an officer-involved shooting? Most of the officer-involved shootings are clearly legitimate use of deadly force. However, there are cases where deadly force may not have been justified. When you go back and you look at the case from Charleston, where the first three days, this is a suspect who ran on a traffic stop. And what the officer said was there was an interaction, there was a fight, he tried to grab my taser, tried to grab my weapon, and I shot him. That was the story for the first three days, until that bystander came forward and videotaped the officer shooting a fleeing suspect in the back. And the fleeing suspect was not a threat to the officer. And this was a case where, on the federal side, the officer pled guilty to violating the civil rights of Mr. Scott and was sentenced to 20 years. Had Mr. Scott not died, again, who is going to address the forensic issues in our nonfatal officer-involved shooting to determine are the injuries consistent or inconsistent? This is the report from the Department of Justice in the Michael Brown shooting in Ferguson. This is the first report of its kind, where DOJ put out this 100 page report to say this was a justified use of deadly force. Okay, so what did they say? Why did they say it? So let's look at the, if we take the Michael Brown case, does your hospital or agency have a protocol to evaluate the forensic issues related to living gunshot wound victims? Meaning who is going to determine the total number of wounds? Who's gonna determine entrance from exits? Are there any retained projectiles? What is the range of fire, meaning distance from end of barrel to clothing or skin? What is the projectile trajectory in the wound path? Is there a chain of custody for the collected evidence, meaning the clothes or a bullet that you might find on the stretcher? And then the ultimate question that, again, the ICP wants us to ask, in are officer-involved shootings, are the injuries consistent with the history given, whether it's by the victim or by the officer involved in the shooting? In the Ferguson case, there was evidence that needed to be collected. There was evidence on Michael Brown's hand that says he was shot actually inside of the officer's patrol car. And this was information that wasn't shared until later on. It should have been shared, because I think if the public had known what had actually happened, that there were two felonies committed against Officer Wilson before he ever exited the car, one he was struck in the face, and two, Michael Brown attempted to take his sidearm. So is there evidence that supports the officer's statements? And there certainly was. Brown's DNA was found inside of the SUV, it was found on Officer Wilson's shirt. There was a discharge range, a close range, a gray wound to Michael Brown's hand that established that Michael Brown's arms or hands, torso was actually inside of the SUV. And this is from that Department of Justice report. But this didn't come out till much later. And we think about all the riots and things that happened as a consequence of Michael Brown's death. So the question is if Michael Brown were shot in a tactical operation in your community and he survived to go make it to your trauma center, who is going to collect the evidence? Who's going to document those wounds and make those determinations, those forensic determinations? The grand jury testimony in the Ferguson case really boiled down to two things that the grand jury returned as no true bill against Officer Wilson. One was the wound documentation and interpretation of the injuries on the officer and Michael Brown. And two, that forensic evidence, blood and bullet inside of the police car. Now what was that? Well, here we have the officer who was struck in the face, that sustained a fracture of the orbit. Do we document that? Who is doing again the forensic evaluation of our injured officer? Well, here's a nice forensic photo with a forensic scale documenting the abrasions to Officer Wilson's face and the area underlying or overlying his fracture. But look at this description. This is from the autopsy of Michael Brown. All this description is about a graze wound. Now from a clinical standpoint, I can tell you, no surgeon, no ER doc cares at all about a graze wound. It may not even make it into the medical record. However, from a forensic standpoint, graze wounds can give us a lot of information including the direction that the bullet went. And when we look at the description by the, Murray Case is the pathologist who is involved in this, Michael Brown's autopsy, look at this description and their interpretation. Forensic interpretation, the graze wound, it says it is elongated with dried edges and associated skin tags. Who cares about skin tags? Well, clinically no, forensically very important. So the skin tags point toward the tip of the right thumb. The path is upward. So what are these skin tags? Then the discoloration near the ventral surface of the right hand, that was soot from the discharge of Officer Wilson's handgun inside of the police car. So here's a graze wound, so what are these skin tags? Well when you look, and is Brian, I dunno if my, is my cursor moving? Here is a skin tag associated with--

- It's moving.

- Okay, great. So here's a skin tag associated with a graze wound. Clinically, who cares about the graze wounds? Forensically, the graze wound, the trajectory of the wound path, here from inferior to superior, is opposite to those skin tags. Here's another graze wound. See these skin tags that point down, that's opposite to the direction of the bullet. Here in a diagram, skin tags pointing down the wound path, it's the opposite direction. So it is important that somebody document photographically at a minimum the wounds associated with an officer-involved shooting because there's valuable information there when it comes to reconstruction of what happened. Unfortunately in the Ferguson case, there was compromise of some of the evidence. Blood was washed away. Now fortunately there was still blood inside the car. There's actually blood on Officer Wilson's handgun. Where did that blood come from? That came from Mr. Brown inside of the police car. His blood dripping on the officer's handgun. And what else from that officer-involved shooting? Officer Wilson said the first time he went to pull the trigger, the trigger wouldn't engage. Well, 'cause it was outta battery and it wouldn't discharge. Important evidence that says Michael Brown was actually inside the car. So, and coming back to the ultimate question for you all, would the grand jury have reached the same verdict, had Michael Brown survived in your trauma center? Who would've performed that evaluation of documenting the injuries, the forensic documentation, the forensic interpretation of entrance, exit, range of fire in the bullet path? So in the chat, if you have a program that can do that, let me know. Because outside of Christiana, where they have the forensic nurses who've gone through gunshot wound training and they're rendering interpretations, I think they're probably very few. Now a question that comes up a lot in emergency departments across the country is HIPAA, and what information can be released to the investigating officer. And if your hospital gets federal funds, and we all do, then this federal regulation dictates what information can be released to the investigating officer. And this may surprise some people, because it includes name and address, date of birth, Social Security number, blood type, but the type of injury. So if an officer comes to you as the treating ER doc, and says, doc, tell me about the injury, that is a permitted disclosure based upon this federal regulation. And what I teach officers across the country is if your hospital, your risk managers say, officer, detective, we ain't telling you anything. Well I say, okay, first go to the risk manager and say are you familiar with this federal regulation? Because if they are not or they say we're not giving you anything, then I'm telling the detectives to call CMS. And that's exactly what happened. I trained this officer, this detective in Salina, Kansas, and look at what he said. He said, thanks for your help. I'll be sure to pass this information along to other detectives. It was a tremendous help, worked like a breeze. Apparently CMS carries a huge stick. They rolled over real quick. So no hospital wants to see a CMS investigator on their doorstep. So please educate your risk managers and your nurses that there are permitted disclosures that that investigating officer can have access to. Now you can't get access to toxicology. But any of these things listed here, the investigating officer has access to. Anybody remember this shooting from LA, where an operator says he steps out of, it's about four a.m., steps outside of his police compound, the building, and there's a sniper out there. And the officer is shot in the shoulder. Apparently a graze wound. SWAT's called out. They think they know the building that the sniper was in. They set up a perimeter, they clear the building room to room because this officer was shot. Fortunately it was a graze wound. However, the officer had faked this. He'd actually taken a pin and stuck it through his clothing and rubbed his shoulder to make it appear that he was shot when he really wasn't. So even fake shootings are something we have to approach objectively. This was an officer who makes a traffic stop in Birmingham. He calls out on his traffic stop, he's on the radio, and in the background you can hear shots fired, and he never completes his radio transmission. The officer called out shots fired. So everybody responds. First officers get to the scene, they find his police car with bullet holes. But guess what, the officer had faked the shooting. So we always need to be objective. And one of the, this is a wild one from Oklahoma, where this officer had a gunshot wound to his belly, had bullet holes in his truck, but they were all self-inflicted. The officer did this and had his neighbor arrested. So even when an officer's shot, what does the objective evidence show? Who is doing those forensic evaluations of those officers? Okay, now Brian, in the chat I'm going to, we're gonna present this case. So the case is SWAT makes entry on a high risk warrant. As they make entry the male suspect 6'3", 240 attacks the first SWAT operator through the door. He places the SWAT operator in a chokehold. And we all understand that a chokehold is deadly force. You can die. So the SWAT operator states that he was able to shoot the suspect in the head with his sidearm just as he lost consciousness. The suspect has two head wounds. The suspect is treated by the tactical medic at the scene, dressings on the head, he's intubated and he is transported to your level one trauma center. Okay, so the question is, for everybody on here, if you're willing to, I'm gonna show you two wounds, the right temple and the left temple. And I'm gonna ask everyone to vote, which wound is the entrance, which is the exit, and what's the range of fire. So this is the right temple. There's the left temple. Okay, so that's gonna be for the SWAT medic to answer. But what about, you're the attending in the ER when this officer-involved shooting comes in. So here's some questions for you, the attending, or the resident or the fellow who is taking care of this. So if you were asked by the investigating officer, doctor, were the physical characteristics of the wounds, let me move this out of the way so I can see it. What were the physical characteristics of each of the wounds on the suspect's scalp? Are you, as the tactic medic or the attending, comfortable in describing physical characteristics of gunshot wounds? Doctor, which wound was the entrance? So if an investigating internal affairs comes in and asks you, doctor, which was the entrance, 'cause this patient is still alive, how would you determine entrance from exit? And how did you determine which was the entrance wound? Which was the exit wound, doctor? How far was the officer's gun from the suspect's head when he was shot? Doctor, if the officer said he placed his arm sidearm against the suspect's scalp as he was about to go unconscious from being strangled by the suspect, are the injuries consistent with his statements? All legitimate questions that could be asked by the investigating detective. So how would you all answer those questions? And we're gonna come back to these again. And so I want you to think about it. Let me go back and just give you the photos. Right temple, left temple. Which is the entrance, which is the exit, what's the range of fire, are the injuries consistent or inconsistent with the statements given by the officer? When we have an officer-involved shooting, we have two scenes. Clearly we have the scene where the shooting occurred, but the individual who was shot, suspect, officer, bystander, hostage, that's our second scene. Those shell casings at the scene of the shooting, they're not going anywhere. Short-lived evidence doesn't exist there. Where short-lived evidence does exist is on our victim who is transported to our resuscitation room. So another question for you is the wound with the chest tube an entrance, an exit, or a medical student putting in their first chest tube? Because having done this for a while, I can tell you that emergency medicine residents, attendings, surgical residents, attendings, if there is a preexisting hole and it's in the place or close to the place where that chest tube could go, it's going in there. And sometimes when chest tubes are placed, because there's a preexisting hole, someone takes that scalpel and makes a nice incision and destroys the physical characteristics of that wound. So is any attempt made to document that wound prior to surgical intervention? So again, does your agency or your hospital have a protocol that could answer these questions on living victims of gunshot wounds to make sure the total number of wounds are documented, entrance from exit, retained projectiles, range of fire, wound path, bullet trajectory, chain of custody, and then that ultimate question, are the injuries consistent or inconsistent with a particular history? Now Brian, would you like to read this X-ray for me?

- Let's see, I see looks like a KUB, and there's overlying shadow. Of course, I can't tell whether or that--

- Actually it's not overlying.

- Or internal, let me just say that there is shadow there that looks suspiciously phallic shaped.

- You're absolutely correct, doctor. This is a sex toy that has been, he fell in the shower, right. So I don't want a defense attorney to say, doctor, please bend over because the tactical medic failed to perform a forensic evaluation of the gunshot wounds in the emergency department that would've helped my client. Don't let this happen to you figuratively. Because we know that when hospitals have no forensic nurses, don't have protocols, that evidence is lost. And whether it's evidence from clothing, from destruction of the wounds, failure to document those characteristics that help us determine entrance from exit and range of fire, it happens all the time. John Smialek, who is the former chief medical examiner in Baltimore, was having such problem with the doctors in shock trauma, great care, shock trauma. But in the emergency medicine clinics in North America, he wrote this. When the emergency physician forms an inaccurate opinion as to the cause of certain findings and then documents that opinion in the hospital chart, it can be used in subsequent legal proceedings. What John was finding was the surgeons at shock trauma were putting in the medical record entrance and exit. But when they came for autopsy, John was finding, no, why did these doctors get it wrong? Well, why were the doctors getting it wrong? And I'll share with you why. This is from my hero and friend, Rich Carmona. He looked at, in Pima County at his level one trauma center, he and Kenny Price found the majority of cases reviewed demonstrated significant forensic medical deficiencies, primarily the area of documentation and or securing of evidence, which means we need to do a better job. Because if this bullet, if there's no chain of custody, what's gonna happen when the prosecution wants to admit this piece of evidence at a trial? The defense is gonna object. And if there's no chain of custody, did this bullet really come from our victim, or the one who came in just 30 minutes before from another shooting? So Rich was onto something. So let's go back to our question. Is this an entrance or an exit?

- Yeah, we have a couple of answers here.

- Okay, what are they?

- The initial answer was larger wound looks like entrance wound if it was a contact wound. But then we have some follow up, which is that there's no stippling noted on the right temple. So thoughts are that it's probably left side entrance, right exit. Again, no powder burns, we're stippling to either side. So unlikely contact. Of course, we also have a comment that says I don't remember if it was CONTOMS or somewhere else, but I thought I remember hearing that if you're not a forensic specialist, you should never give official commentary about these to a LEO, and that also any decent attorney will eat us alive on the stand.

- Okay, so what that says is we can describe, and I was talking with Brian about this earlier, a patient comes in with a rash, we will describe that as macular, papillae, vesicles, whatever it happens to be. Why don't we do the same description with gunshot wounds? There are fewer descriptions of gunshot wounds than there are physical characteristics of rashes. But why do we stay away from gunshot wounds? Well, so here we go. How well do ER docs and trauma surgeons do at determining entrance from exit? Well, this was the very first study done by two forensic pathologists that took 100 patients who went to a level one trauma center with gunshot wounds but then died and were autopsied. When there's only two holes, an entrance and an exit, the physicians were correct 63% of the time. How many people want to go to a doctor who's correct 63% of the time at diagnosing their chest pain as a MI? No, we don't, we can do better. But when there's more than two holes, the doctors were correct 27% of the time. So why are physicians, whether it's surgeons or emergency physicians, rendering these incorrect opinions? And then getting back to, I will share with you the way we can render opinions and the way forensic pathologists render opinions is based on the wound characteristics of that particular wound. So what that says is we need to be better at understanding what physical characteristics are there and how to describe those, how to document those. Even if we don't want to render any opinion, we should at least at a minimum be describing those wound characteristics. But if we look at, in this article out of J of Trauma, wound characteristics are only documented in this study 10% of the time, which means 90% of the wounds were not documented. And this out of JAMA, or this was from Marty Fackler. Data shows that adequate physical exams have location, size, shape of the wounds recorded in less than 3%. So we clearly have room for improvement. So our goal, whether it's as a tactical medic or whether it's as a physician in the ER or provider in the ER, excuse me, is to preserve any short-lived evidence prior to surgical intervention. Because what's gonna happen when that patient goes to the OR? Well, things are gonna get washed away. The surgeon will take that 11 blade scalpel and make nice clean wound margins, and they will have destroyed evidence. So our goal is to document that prior to that patient going to the surgical suite. Because post-op, what's this, entrance, exit, can I tell you? No, you can't tell. So how do we determine entrance from exit, and what physical characteristics should we be documenting regarding those wounds? Well, there are a couple things. When we look at an entrance wound, we're looking for what's called an abrasion collar, which is a pure friction phenomenon. We're looking for soot, the carbonaceous residue from the burning of gunpowder, that black material right there. We're looking for tattooing or stippling. And we're also looking for triangular shaped tears with associated soot and seared skin. And that comes from with a contact with the gases and the flame being injected into the wound. So that's what we're gonna be looking for on entrance wounds. On exit wounds, irregular borders, no soot, no tattooing, and no abrasion collar with one rare exception, called a short exit. Now let's go, I want everyone to get in on the chat. We have two wounds here. We have one wound here. Both of these wounds were caused by a .22 long rifle. We know this is the entrance because we see the soot. Therefore this is the smaller exit. This is also an exit. So why is this exit small and this exit large when it's the same caliber, same velocity, same potential energy of a .22 long rifle? Why is one small and why is one large? Anybody want to try and answer that? Same velocity, same caliber, same potential energy, small exit versus large exit. Brian, anybody willing to weigh in on that?

- Don't see any, wait, wait, nope, we got a taker. The answer, distance.

- Okay, well--

- The proximity. Also, hit a bone and rolled.

- All right, distance, not a factor, 'cause this is close, 'cause we've got soot. But whoever said bone, they are correct. So what dictates the size of that exit wound is the energy transfer to underlying tissue. Here, it went right through the gasrock, split the skin, goes downrange here, it hit the radius and ulna, energy transfer, large exit. So the six physical characteristics that are common to entrance wounds are, and this is what causes them, the abrasion collar, which is created by friction between the bullet, the unburned gunpowder, which will create the tattooing or stippling. The burned gunpowder will deposit as soot. The flame that comes out of the barrel will actually sear the skin. The injected gases will cause triangular shaped tears with associated soot. And then you may see what's called a muzzle abrasion or muzzle contusion with the contact wound. And so now we're going to work through each of these physical characteristics. And this information is also in your handouts in the packet. So what's the abrasion collar created by? What's tattooing created by? The soot, seared skin, triangular tears and the muzzle contusion. So when a handgun is discharged, there are a lot of things that come out of the barrel other than the bullet. The bullet will create that abrasion collar, but look at all the other material that's coming out of that barrel. The unburned pieces of gunpowder, the burning pieces of gunpowder, the soot, the flame, and the hot gases. So all that comes out and will help us determine entrance from exit as well as range of fire. The range of fire is defined as from the end of the barrel to either the clothing or the skin. And depending on what we see on that skin, for example, if all I see is an abrasion collar, all I can say it's distant or indeterminate, meaning I can't tell you how far, could be five feet, could be 500 feet. If I see the abrasion collar and tattooing or stippling, that's going to be the intermediate range, which is generally defined as 48 inches or less. Now there's gonna be some variability depending upon the length of the barrel, the type of charge, whether it's a magnum round or a regular round. But if you see an abrasion collar and tattooing, you feel safe in calling that an entrance at an intermediate range. Now what that is could be 24, 36, 48 inches. All you can say it's intermediate range. Now if you see the abrasion collar and soot, and you may see tattooing as well, that's going to be close range, which is generally defined as six inches or less, maybe a little more, a little less depending upon the amount of powder in any particular cartridge. And then if you see soot, seared skin and triangular shaped tears, it's contact. So they're basically four ranges of fire. And again, this will be in your handouts. So if I see seared skin, triangular shaped tears and soot, it's going to be a contact wound. If I see soot in abrasion collar, it's going to be a close range, which is somewhere zero to six. If I see the tattooing and the abrasion collar, I'm gonna call it intermediate. And if all I see is the abrasion collar, all I can say is distant or indeterminate. From a forensic standpoint, the most important question you can ask any patient who's been shot is how far away were you from the gun when you were shot? And I was talking earlier with Aaron, our EMS fellow at at U of L, that he uses this information all the time to get the history, and then he looks and says, no, when you tell me you were shot in the drive-by and I see soot on your hands, liar, liar, pants on fire. So the benefit of knowing how to take physical findings and translate that into consistent or inconsistent is very important. So let's look at a distant wound. So the only thing that's gonna hit the patient's skin is the bullet. And when that happens, there is friction between the outside of the bullet and the skin, which will create friction, creates abrasion. So we call that an abrasion collar. And this is what the abrasion collar looks like. It's where the epithelium is actually stripped away from friction with that bullet and the skin. So here we have the abrasion. Here we have our tissue defect where the bullet continued through the scalp, all this is the abrasion collar. So what would you describe in the record? I've got a wound. You can give the location, the size and the tissue defect with an abrasion collar, no soot, no tattooing. Perfect, just describe the abrasion collar. Now if that bullet comes in on an angle, so there's more friction with this side of the bullet than this side on the epithelial tissue, we create what's called a comet tail abrasion collar. And this is important because with this comet tail abrasion, what that tells me when I'm trying to reconstruct a shooting is that the bullet came in on an angle, not straight in, but on an angle. And particularly when I'm reconstructing an officer-involved shooting and I'm taking the stories of each individual, when I see this, so here we have the abrasion collar from 12 to six o'clock, comet tail abrasion, I can tell you the direction that the bullet is going. And in this case it is from right to left. Now clinically this is important because if I know the tissue defect is here, any organ system to the right isn't going to be affected. The bullet here then tracks this way. So that may help you in where do I need to put the chest tube in or not? Excuse me, here's another comet tail abrasion collar. There's our tissue defect, the bullet's going off to the right. So the projectile is going from left to right, enters on an angle, scrapes away all this tissue. And what I would hope to see in your chart would be comet tail abrasion collar. Okay, so now we have a test question. Clearly we have a comet tail abrasion, comet tail abrasion, comet tail abrasion. So all the bullets are coming from right to left. Look at this photo and tell me what is the range of fire, meaning distance from barrel to skin, and why? So the question, Brian, for our audience, what is the range of fire of these three entrance wounds? Any takers?

- [Brian] We got greater than six inches is our first answer.

- Okay, give me a range. Contact, close, intermediate or distant. Four ranges of fire.

- [Brian] We got intermediate, intermediate.

- Perfect, the intermediates have it. And why is it intermediate? Those that said intermediate, what is your opinion based on?

- Stippling present.

- That's right. We have actually, here's our tattooing or stippling. And actually right here you can see there are two pieces of gunpowder. Another piece of gunpowder up here. So those punctate abrasions called tattooing. Now sometimes a bullet will go through an intermediate object. And when it goes through an intermediate object, a door, a windshield, something, the bullet, instead of going nice and smooth, spiral downrange, it's going to become unstable and tumble. The wound on the right is our typical entrance wound. Nice smooth abrasion collar. Slight comet tail here. This is what an atypical entrance wound looks like. 'Cause this was an officer-involved shooting, this was a 40 caliber round that went through the windshield as a suspect was driving toward an officer. And so this is kind of gnarly looking. That's because the bullet, one deformed as it went through the windshield and then became unstable. Okay, let me give you a real case. This is Sergeant John Mattingly's anterior left thigh. And if you can see it here at the top, I called this an atypical entrance wound. And remember John was first through the fatal funnel when he was making entrance into Breonna Taylor's apartment. When a shot rang out, he went down. And that's when all the rounds started going into Breonna Taylor's apartment. But let's take a close look at his wound. It's very gnarly, isn't it? And it looks like bruising around the wound. So I'm gonna show you two wounds. This is the wound on John's anterior thigh, and this is the wound on the posterior aspect right underneath his left butt cheek. Okay, so you've got two wounds, no retained projectile. How do we determine was he shot by a fellow officer from the back and exited out the front, or did the round come, as John said, from inside Breonna Taylor's apartment, struck him in the leg as he made entry and then exited out his butt? What does the physical evidence show? Because remember what the plaintiff's attorney said? No, he was shot by a fellow officer, not by his client, inside of Breonna Taylor's apartment. Well, when we look at the X-rays, we have our marker on the wound on John's left anterior thigh. The reason John's wound is atypical, let's go back to John's wound. Why is it so gnarly? It certainly is not a typical entrance wound. It is because it went through an intermediate object. In this case, John had his wallet in his left front pocket. So when that nine millimeter round penetrated his clothing and then went through the pocket and into his wallet, the bullet became unstable and deformed, which is why it created that atypical entrance wound. However, when we look at John's pant, the wound, the bullet that comes in the front, this is before it became unstable, gives us a nice smooth defect in the cloth. Nice, smooth. So that tells us that when the bullet entered his pant, it was stable, spiraling. It became unstable when it hit his wallet. And this is looking at the inside of John's pant. This is the bullet coming in from the front toward the back. There's the nice defect. But look what happens after that nine millimeter round hit John's wallet. It took the energy, transferred it to the wallet, and actually blew out the inside of his pocket. It entered here, went anterior to posterior, medial to lateral, exits here, just under his left butt cheek, gets the superficial femoral as it penetrates. And here we see it on CT, and exits. So the importance of documenting John's wounds, when I first came into the ER and I talked to the resident that was taking care of John, she told me there was only one wound. And I looked at the film, I said, where is the retained projectile? And she just kind of shrugged her shoulder. That's not important. She had missed the wound underneath his left cheek. So it is critical because when we get sued, when our officers, our department gets sued, we want to make sure that any opinion that is rendered is based on good physical evidence and that wound documentation. So at the intermediate range wound, which is abrasion collar and tattooing, what does that look like? Well, all of the gunpowder that is in that cartridge is not burned when that cartridge is discharged. So yes, you have burned gunpowder that creates the pressure within your cartridge case. It pushes the barrel, the bullet down the barrel, but not all of that gunpowder gets consumed. And so unburned gunpowder is going to be coming out of that barrel as well as burning gunpowder. And the variables associated with the presence or absence of tattooing, how much gunpowder's in that cartridge, the length of the barrel, the muzzle to target distance, are there any intermediate objects like clothing or a window that will stop the unburned gunpowder from making it to the clothing or the skin, wind, and then there's actually the shape of the powder will dictate how far it's gonna go downrange. 'Cause ball powder is going to go further downrange than the flake powder that's going to tumble as it comes out the end of the barrel. So what does tattooing or stippling look like? These are punctate abrasions in the skin caused by unburned or burning pieces of gunpowder. Here's our abrasion collar, actually, you can see it's a comet tail abrasion collar. There's our tissue defect. So if we see this on a patient, we know, one, it's an entrance wound, and two, it's an intermediate range of fire. So if they give us a history, yeah, they were shot in the drive-by, and well, how far away were you from the gun when you were shot, and they say 30 feet, liar, liar. Physical findings not consistent with that history. This is tattooing at 24 hours. Because it is a punctate abrasion it will stay around longer than say soot will stay around. Abrasion collar and tattooing. And when we want to photographically document these findings, we always want to take our forensic photo at 90 degrees with and without a ruler. And the reason that's important is because, okay, when we look at this officer-involved shooting, we can say that the majority of the tattooing is within a 60 millimeter range. Okay, well, why is that important? Well, when we go to the crime lab and we test fire the officer's weapon with the same ammunition, at what range do you get the majority of your tattooing in that 60 millimeter range? That's important because the officer says, as it was in this case, he was about 10 inches away when he had an accidental discharge, versus the suspect who says he was five feet away, and he shot me for no good reason as I'm out taking my afternoon jog. So in this case, physical evidence is consistent with what the officer said. Close range wounds, what are our physical characteristics? Abrasion collar and soot. So here we have the abrasion collar, but the most important is we have soot, carbonaceous residue from the burning of gunpowder. When we see soot, we're gonna say it's close range, and generally six inches or less, maybe an inch or two either way. Now I heard somebody in the comments call this a powder burn. Take that out of your vocabulary. You do not want to call this soot material a powder burn. And I'll share with you why. Here's soot on clothing. Let me show you deposition of soot in this video that I created. This is a .40 caliber Glock. Look at that soot. And you can even see unburned pieces of gunpowder coming out the barrel, if you can see those flakes. But we're gonna call that carbonaceous residue from the burning of gunpowder soot. Okay, so let's kind of take this backwards. So this was at six inches. Look at that soot and the gases deforming the T-shirt as we discharge into it. Okay, soot. Okay, now, this is soot, this is short-lived evidence. This is what we need to be describing. Whether it's at the scene, in the back of the ambulance, in the back of our bearcat, whatever it is we're transporting the patient in, we want to be able to say what was there before they got to the ER. And hopefully in the ER someone will also be documenting the presence of soot surrounding this wound to the back of the neck. 'Cause what that tells us is this is a close range wound. Here is soot on the hands. This is what we want to call it, soot. And Aaron was talking earlier about soot on somebody's hands. This is from gap flash with a revolver, where we actually get soot and flame going out horizontally, because where the cylinder and the barrel come into contact with each other, there is a gap there, and you can get soot and hot gases going out horizontally as well as out the barrel. Here we have a wound on the right temple with soot and tattooing. There's the tattooing. But what is most important is when you see soot, you're gonna call that close range, six inches or less. Okay? Now that term powder burn that somebody wanted to use, what is a powder burn and why is it we do not want to put ever put that in a chart, if we're dealing with smokeless powder associated with all commercially available cartridges. So what is a powder burn? Well powder burn is associated with the use of black powder. Where do we find black powder? In a muzzle loader, starter pistols. If you were shot by Daniel Boone or Davey Crockett with a muzzle loader, And the ball of fire that comes out of a muzzle loader with black powder does not burn as efficiently as the smokeless powder. And I'm gonna show you a video of this huge fireball. So when this fireball comes out, it catches your clothes on fire, and your clothes burn, and creates a thermal injury to your skin, that is by definition a powder burn. So let me show you a powder burn. Here's a .50 caliber muzzle loader. Look at that ball of fire that's coming out with black powder, look at all that. Black powder does not burn efficiently. So it then catches your T-shirt on fire. So if you use that term powder burn, you could have a smart defense attorney that says, doctor, you described this as a powder burn, that's correct. They're gonna have you read what a powder burn is. So are you telling the jury, doctor, that this individual was shot with a black powder weapon? And you weren't, you were describing soot. So you call that carbonaceous material soot. And don't call it a powder burn. The other range of fire is contact. And this is where physicians, nurses, paramedics get themselves in trouble because it's these contact wounds that can create huge entrance wounds from the injection of gases into the skin. So when the barrel is in contact with the skin, the bullet's going in, the hot gases are going in, the soot, and the skin's gonna expand just like a balloon, and it's gonna expand to a point where it can't expand anymore. And when it gets there, then it's gonna rip and tear. And it rips and tears in the same way every time. And how does it rip and tear? Well, when these gases get injected in, and that skin expands and it can't expand anymore, we've reached the elasticity limits of that tissue, wherever it happens to be in the body, then you get triangular shaped tears associated with that contact wound. Look, this is a contact with a .38 to the forehead. Look at these triangular shaped tears. The apex of that triangle is pointing away from where the gas was injected. So when I see this wound, I see triangular shaped tears, soot and seared skin. When you see those three, triangular shaped tears, soot, seared skin, it is a contact wound and cannot be anything else, period. It's a contact wound. So soot, seared skin, triangular shaped tears. And that's what you should be documenting at a minimum when you see this patient. what are the physical characteristics? Soot, seared skin, triangular shaped tear. You should know that has that wound created because it was a contact wound. So let's look at contact wounds with different calibers. Here's a contact with a .22. How do we know it's a contact? And how do we know it's an entrance contact? Well, here we have soot, and if you look closely, you have those small triangular shaped tears. Where does that come, the triangular shaped tears come from the skin as it expands. Now a .22, small caliber, small amount of gunpowder, therefore small amount of gas injected into the skin. Here's a contact with a .32. A little larger cartridge, a little more gunpowder, therefore a little more gas. But what are the physical characteristics of that wound? We have soot, seared skin, triangular shaped tear. You see those, it's a contact wound, can't be anything else. And we have a bonus on this one. Here at the three o'clock position, we have a muzzle contusion or muzzle abrasion. That occurred as that skin expands and then it pushed against the barrel of the weapon, leaving this abrasion or contusion at the three o'clock position. Here's a contact with the .380. Again, larger cartridge, a little more gunpowder, therefore larger triangular shaped tears. Contact wound to the right temple. Now forensically, this is the weapon that actually caused that wound. Look at the blowback. And I'll show you a video where blowback comes back from the entrance wound onto the barrel or the frame of the weapon. And with a semi-auto, as the slide goes back, you may actually find pieces of tissue, brain, bone on the barrel that has been covered up by the slide. Contact, .38. Why do we know it's a contact, therefore, an entrance contact. We see triangular shaped tears, apex of the triangle away from where the gas was injected, soot, seared skin. And then we have a muzzle contusion from the three to nine o'clock position. Now do not let anyone tell you that they can tell you the caliber of the bullet based on the characteristics of the wound, doesn't exist. So here's a question, and I expect Aaron will get this, which is a larger caliber, a .38 or a .357 Magnum. Who's gonna answer that question? Other than Aaron or someone who's had this class before? Which is the larger caliber, .38 or .357 Magnum? Any takers?

- [Brian] Yeah, well we've got, yeah, so we've got three answers, we've got .357, we have relatively interchangeable, and then we have basically same caliber. And I'll just add in there, you know, same round size, just longer case with more powder.

- That's right. So here we have two bullets, exactly the same caliber, 0.357 inches in diameter. What is the difference between a .38 and a .357 Magnum? Well, here's our .357 Magnum contact wound to the head. Okay? The difference is the Magnum round has 40 to 60% more gunpowder, which means, one, the higher velocity of the bullet as it exits. But when it comes to forensics, more gas. So more gas injected into the skin, larger triangular shaped tears. So let's review our entrance wounds. All entrance wounds will have an abrasion collar except when the wounds are on the palms and the soles of the feet. And that's because of the keratinization of the skin. If we see triangular shaped tears, muzzle contusions, soot, severe skin, it's contact. If we see soot, we're gonna call it close range. And if we see the abrasion collar and tattooing, we're gonna call that an intermediate range, something less than 48 inches. Okay, so that's it. Now, where do emergency physicians, trauma surgeons get themselves in trouble in rendering incorrect forensic opinion? It's because they base their opinion on the size of the wound. So as my residents know, I tell them size doesn't matter in gunshot wounds, maybe other things, but not gunshot wounds. Because here is an exit wound from a nine millimeter after it's gone through the C-spine, splits the skin and falls to the ground. So an exit wound smaller than the associated entrance. Here we have two exit wounds. We see triangular shaped tears. So how do I differentiate is this a contact wound with triangular shaped tears from gases, or is this an exit wound with triangular shaped tears? So we have to look at the physical characteristics. Do I see any soot or seared skin? No, I don't. Therefore, it's gonna be an exit wound. And this is, this was an officer-involved shooting with non-bonded ammo, non-bonded because the core of the bullet and the copper jacket separated after it entered the body. This exit wound is from the lead core. This exit wound is from the jacket. So we call this a compound exit wound. Exit wound from the bullet, exit wound from the jacket, non-bonded ammunition. So here's another triangular shaped wound. This is an exit wound. How do we know? Well, I see triangular shaped tears, but is there soot or seared skin, no, there's not. Therefore, it is the exit. So this is your decision tree. I've got a triangular shaped wound. Do I see soot and seared skin, then it's a contact entrance. No soot, no seared skin, it is an exit. We talked a little bit about what determines the size of an exit wound. Now it's energy transfer to underlying tissue. That's the number one cause. Bullet shape, could mushroom, could yaw, may influence. But the number one factor is that energy transferred principally to bone. And something that people don't think about, at least in living victims, is that swelling of underlying tissue. I've seen an exit wound go from a centimeter to 10 because of hemorrhage within the underlying tissue. So here we have a bullet going through an intermediate object. That's gonna cause it to go unstable. Now there are some bullets out there that are kind of novelty rounds. This is the RIP round, which can create up to nine exits from a single bullet. We have eight petals and a base. Now we know this is an entrance because there's our comet tail abrasion collar. But look, all these exit wounds from, this is probably the base, and these are the petals that are exiting. Remember our .22 long rifle example for exits, small exit, large exit. The only difference was what did the bullet transfer its energy to? Here it went through muscle, no energy transfer. Here it hit bone, large energy transfer. So here is our triangular shaped tears, no soot, no seared skin, therefore it is an exit. So look at those physical characteristics. Here's another exit from a .22 long. Triangular shaped tears, but no soot, no seared skin. Therefore it is an exit. And here are just some other examples. Here we have triangular shaped tears. Where's the entrance wound? Right here under the chin with soot and seared skin. Here we have a rifle round of .308s. Rifle rounds also create abrasion collars. This .308 hit the tibial plateau and that's what happened. So energy transfer, rifle rounds clearly have way more energy than handgun rounds, but it's that energy transfer that causes the exit wounds to be large. There are a few unusual cases. Here we have a triangular shaped tear, maybe a hint of soot right here. But this is an exit, because here's the contact entrance wound right underneath. And sometimes if the tissue is thin enough, that soot may actually transfer or be pushed through the wound and come out on the exit side. But here we see our triangular shaped tear, soot, seared skin. So let's go back to our original question. And let me see who is going to, who would like to answer the first question? Doctor, what were the physical characteristics of each of the wounds you observed on the suspect's scalp? How would we describe these? How are we going to determine which was the entrance and which was the exit? What's the range of fire? How did you, so if the officer says that he put his gun up to the suspect's head, are the injuries consistent with a contact wound from the SWAT operator's handgun as he's attacked by the suspect as he makes entry? And doctor, if the officer says he placed the gun against the suspect as he was about to go unconscious from being strangled, are the injuries consistent with his statements? How many of you are now comfortable at least documenting? And if you want to, if whenever you interpret a wound, if you always put what your opinion is based on, based on physical characteristics, well, it's a entrance wound, close range, because I see soot. Or, if we look at this right temple, that's the soot, seared skin and triangular shaped tears. Therefore, it is a contact wound and would be consistent. So I think we're about out of time, Brian, and I think we're at the end. But this is in fact a contact entrance wound. Here's our soot and seared skin. Here's our triangular shaped tear. And there's actually another one that extended outwards, backwards, but that's where the barrel was. The gases get injected, the scalp expanded, and created that huge entrance. This is the associated exit. So here is, now it's time for our question and answers. That's my email, this is my phone number at headquarters. What questions do you have? What challenges do you have as the tactical medic? What challenges do you have at the ER? Do you have forensic nurses who can assist you, and keep you from going to court? So Brian, where are we?

- [Brian] Yeah, do we have any questions out there? If so, put your hand up and I will click on you, trying to find all of our participants here. All right, I can't find you all. All right, I guess, actually, if you, no, I don't see any hands up. Do we have any questions? Wait, wait, let's see. We got, here we are. We do have some questions, though, actually coming through in the chat. Anything wrong with just calling it suspected gunshot wound in the emergency department, which seems like the safest.

- That's I think a little bit of a cop out. I would ask every emergency physician, every resident has the knowledge to describe what they see, and that's what should be our minimum standard. What do you see when you look at a wound? We can do that as part of physical diagnosis. And if we know there are only six potential things that it could be, abrasion collar, soot, seared skin, tattooing, triangular shaped tears, use those simple terms to describe what you see. Because it may be like, in the case of Sergeant Mattingly, if a forensic evaluation hadn't been done and the resident only found one wound or, and then they say, well where's the other bullet? Or yes, now we found an exit wound, we found a wound on the his butt cheek and we found a wound on his anterior thigh, which is the entrance? Did the bullet come from front to back or back to front? And if we don't have those physical characteristics documented, that plaintiff's attorney may get millions of dollars from your agency because we didn't know. No one did that living forensic exam. So if we describe those physical characteristics, that's what I like residents to do, just describe what you see. Don't have to interpret, you don't have say entrance or exit, but you can take that knowledge and be able to say it's consistent or inconsistent. Particularly when you're dealing with somebody who comes in with a gunshot wound. Now, no one wants to discharge a suicidal patient. So if a patient comes in with a gunshot wound and they say, yeah, I was shot in a drive-by, but you look at that wound and you see there's soot and seared skin, did he shoot himself or herself? Why are they not being truthful? You don't want to discharge that patient who is depressed to go out and then be successful if they had attempted to do harm to themselves. So there are benefits to the patient. There are benefits to the criminal justice system. And I think just across the board we need to be training our residents to just describe what they see, based on physical diagnosis.

- [Brian] Yeah, we have a comment that I guess sort of leads you to a question which is, yeah, I prefer to advise using terms such as a penetrating wound or a sized wound. Also advise describing punctate markings present, areas of skin discoloration, and presence or absence of stellate markings. In other words, it sounds like a more forensic description without actually making any direct comment on, again, entry, exit, et cetera. Thoughts on that, sir?

- And that's fine. As long as they describe, and I think you just describe your positive findings. So if you say there's soot or there's tattooing, any individual with forensic training could come along behind you. Now Aaron, are you still on? Let me ask, 'cause Aaron was one of my residents.

- [Aaron] Yes sir.

- Do you think this is, you've had this lecture several times. How do you use it in when you're seeing gunshot wound patients in the emergency department? Is it a benefit?

- [Aaron] It's definitely a benefit because you kind of help with, especially when you have the homicide detective coming in our resuscitation bay and concerned, you know, is this, one of the biggest questions I have is do you think this is self-inflicted versus is it a true homicide or does the story meet where the family's telling the police? And so it really helps, from a law enforcement side to kind of have an idea of what we're looking at. And that's helped, you know, either send the homicide detective home for the night or to continue the investigation. It also helps on the documentation. So I document that, you know, and having this lecture multiple times has really helped me become more proficient in documenting them and also teaching other residents in our trauma bay and having them correctly document it. I think, I haven't had any experience with that subpoena wise, but I know some of the attendings who have been subpoenaed have been very grateful for some of the documentation I've had because it really has kept them from having to go to court to testify, because it basically is consistent with what the forensic pathologist or the medical examiner has documented.

- Good, now, and sometimes, you know, clearly the more times you see this lecture and review the material, the more ingrained it will be, where it just becomes routine when you describe a wound. I do like, I'm glad, and one of the things I've trained our residents in is what's the difference between an incision and a laceration? And a lot of people get this wrong. An incision is from a sharp-edged implement, a knife, a piece of glass, whereas a laceration is from blunt force trauma. So when someone takes a knife to the wrist, it should be described as an incision, because the edges are nice and clean, not a laceration. 'Cause a laceration implies blunt force trauma.

- [Brian] We have one last question here, which is, does powder residue show up differently under a woods lamp?

- Yeah, powder residue, and there's something also called bullet wipe that can be deposited. They're our alternative light source that our crime scene technicians use, where you use a 415 nanometer light source, a Woods lamp is ultraviolet, orange filter. So yes, you can, there are different wavelengths where you can pick up residues, gunpowder, soot on items, particularly where if it's a dark piece of clothing, may not be visible to the naked eye. There are several tests that are available to the crime lab. One is alternative light source photography. The others are, one's called sodium rhodizonate, which looks for vaporized lead. There's a test called the modified Bryce that looks for embedded pieces of gunpowder, which, I guess we didn't have time to talk about evidence in this case, but when you collect clothing from a gunshot wound victim, please put each article of clothing in a separate paper bag so there's no cross-contamination.

- [Brian] Excellent, so I think we're gonna need to wrap this up. Hopefully you all have taken down Dr. Smock's contact information. I just want to say, by the way, Dr. Smock, for the handout, we actually, the section members do not have the handout yet. What we need to do is we're going to post it up on the members only section website and Deanna, I'll need to reach out to you, 'cause we need a release form in order to get that posted there. But that is going to be available for section members. And section members, we'll let you know once we have that posted. And I just want to say a really big thank you here to Dr. Smock, that really was an exceptional webinar. Really, really useful information, extremely relevant to our work as tactical medical professionals. And we really appreciate you taking the time, and we're looking forward to your, your next webinar.

- Yeah, we'll do strangulation next. And again, this is practical information. If you have any questions, feel free to give me a call, send me an email. But once you get the handout, feel free to copy it for members of your team.

- Wonderful, thank you again, sir. And I guess I'll turn it back over to Rick and Deanna, anything else from the ACEP side of things?

- Thanks Brian, yes, those of you that would like to claim the CME credit for the presentation, Deanna will be sending out a link for a CME survey on the course, and you have to complete that prior to getting any CME credit. It'll be coming out shortly. And I'll just say, Dr. Smock, I was very interested to see you on several of the crime TV shows recently, where you were the medical expert on several of the murder investigations. Very interesting to see you both here and on the TV show.

- Yeah, the Dateline, the Sisterhood, the one from the Denver homicide where he killed the wife, put her in the bathroom.

- Yes, yes, very interesting. So I think that's about it for us. Again, thanks everybody for attending, and again, watch for that survey and for the CME information.

- Excellent, thank you all and have a terrific night.

- Have a good night, thank you.