P. Schmidt

Fatal outcome of a sand aspiration

Although extensive deep aspiration of sand, gravel, or dirt is a very rare incident, its consequences may be severe ranging from the necessity of immediate intensive care to death. Cases reported so far were due to external causes such as cave-ins, near drowning, or being buried under sand masses. We report a case of a 2 1/2-year-old boy who ingested sand while playing in a sandbox with his older brother. Despite early resuscitation and endotracheal intubation efforts, he died subsequently showing clinical signs of asphyxia due to airway obstruction. Autopsy revealed sand masses obstructing the trachea and lobar bronchi of both lungs as well as brain edema, while no signs of blunt trauma, forced sand ingestion, or preexisting medical conditions were found. This case demonstrates that fatal self-administered sand aspiration may occur in early childhood. The pathophysiology of the lethal outcome with regard to the physical properties of sand and implications for the clinical assessment of emergency situations are discussed.

Skull Injuries Caused by Blows With Glass Bottles

Six cases of blows with glass bottles on the skull are reported. The glass bottles varied in size, weight, shape and filling level. In all cases the bottles broke, but there were no fractures of the skull or injuries of the brain or meninges. As consequences of the blows with the glass bottles bruises, lacerations and incised wounds were seen. The only cause contributing or leading to death was a fatal bleeding from lacerations of the scalp.

A fatal case of CO(2) intoxication in a fermentation tank.

Carbon dioxide (CO2) is an odorless constituent of air. Higher concentrations can be detected in geothermal and automotive emissions, fermentation, and sublimation of dry ice. An unskilled worker entered a fermentation tank to clean it, which had not been done for about 5 months allowing for high concentrations of CO2 to build up. A second worker entered the tank to rescue the first one. Shortly after both were found the first worker was rescued directly whereas the tank had to be rotated to pull the second worker out. Cardiopulmonary resuscitation was successful only for the first worker. Medico‐legal autopsy showed bruises, hematoma, myocardial hemorrhage, and edema of the lungs. The right lung was vacuum degassed in an argon atmosphere and quadrupole‐mass‐spectrometry showed an elevated CO2 content in lung gases. Thus, CO2 intoxication/asphyxia in a vitiated atmosphere due to fermentation of wine mash was established as the cause of death.

Occupation-Related Suicides

This chapter focuses on occupation-related peculiarities of suicides. It is intended to elucidate problems that may arise in occupation-related suicides and to provide approaches and solutions for practical forensic casework. A number of suicides with outstanding occupation-related features observed by the authors are presented and compared with analogous observations reported in the literature. Several common characteristic features related to the respective occupational background can be derived from those case reports. Among others, characteristic features comprise availability and easy access to the used tools (e.g., drugs, poisons, special equipment, self-constructed machinery). Furthermore, special knowledge and skills provided by the suicidal individual’s occupational background and practice are applied (e.g., injection and dissection techniques as seen in physicians and related professions or the use of extraordinary self-constructed weapons by technicians). As for adequate interpretation of autopsy findings, patterns of injury initially not in line with criteria of self-infliction often can be interpreted correctly when taking occupation-related modification of an usual suicide method into consideration. With special regard to outcome of toxicology, appropriate consideration of the suicidal individual’s profession may focus attention on rare and uncommon toxic agents that are usually not taken into account and that are not detected when only routine toxicological screening methods are employed. Suicides with occupation-related backgrounds usually present with highly individual and uncommon modes of commitment and peculiar forensic pathological findings that are difficult to recognize and assess. Supplementing the experience by case reports provided in the literature is an indispensable prerequisite to handling cases of occupation-related suicides in a professional and competent way.

Vascular rupture—a rare lethal complication of neurofibromatosis v. Recklinghausen

Neurofibromatosis type 1 (NF−1), a phacomatosis with an incidence of 1:3,000–4,000, is characterized by multiple benign nerve tumors, skin café-au-lait spots and a variety of other dysplastic abnormalities, e.g., of blood vessels. On rare occasions NF−1 is associated with arterial dysplasia (vascular neurofibrosis), which is poorly defined and can result, e.g., in stenosis, rupture, arterio-venous fistula, or the formation of aneurysms. Although a rare feature of neurofibromatosis, haemorrhage, e.g., after minimal trauma, is a potentially lethal complication of this disease. We report the case of a 40-year-old woman with a history of NF−1 who collapsed gasping for air and died subsequently. Autopsy revealed a massive cervicomediastinal haematoma with compression of the neck region due to a vessel rupture without an adequate trauma. This fatality demonstrates that, in rare cases of NF−1 patients, the possibility of internal haemorrhage due to vessel rupture being the cause of death should be taken into consideration in medicolegal investigations even as a spontaneous event in the absence of an adequate blunt trauma.

Blunt force impact to the head using a teeball bat: systematic comparison of physical and finite element modeling

AbstractnBlunt head trauma secondary to violent actions with various weapons is frequently a cause of injury in forensic casework; differing striking tools have varying degrees of injury capacity. The systematic approach used to examine a 19-year-old student who was beaten with a wooden teeball bat will be described. The assailant stopped beating the student when the teeball bat broke into two pieces. The surviving victim sustained bruises and a forehead laceration. The State’s Attorney assigned a forensic expert to examine whether the forces exerted on the victim’s head (leading to the fracture of the bat) were potentially life threatening (e.g. causing cranial bone fractures). Physical modeling was conducted using a pigskin-covered polyethylene end cap cushioned by cellulose that was connected to a piezoelectric force gauge. Experiments with teeball bats weighing 295–485xa0g demonstrated that 12–20xa0kN forces were necessary to cause a comparable bat fracture. In addition to physical testing, a computer-aided simulation was conducted, utilizing a finite-element (FE) method. In the FE approach, after selecting for wood properties, a virtual bat was swung against a hemisphere comprising two layers that represented bone and soft tissue. Employing this model, a 17.6xa0kN force was calculated, with the highest fracture probability points resembling the fracture patterns of the physically tested bats.

[Causes of death in nursing homes--a retrospective autopsy study].

Zusammenfassung34 Todesfälle im Altenheim aus dem Bonner Sektionsgut des 10-Jahres-Zeitraums 1991–2000 wurden retrospektiv im Hinblick auf ermittlungsseitige Fragestellungen, Todesursachenspektrum und Relevanz der rechtsmedizinischen Untersuchungsbefunde für den Verlauf des Ermittlungsverfahrens ausgewertet. Das Untersuchungsgut besteht aus 22 Frauen und 12 Männern im Alter von 62 bis 102 Jahren. Die Fragestellungen der Sektion umfassten allgemein formuliert Fremdverschulden, Pflegefehler, ärztliches Fehlverhalten, Vergiftungsverdacht und die Todesursächlichkeit von Sturzgeschehen. Als Todesart, bzw. Todesursachen fanden sich 21 natürliche Todesfälle (akute Koronarinsuffizienz, Pneumonie), 9 nichtnatürliche Todesfälle (Unterkühlung, Bolus, Verbrühung, Sturzfolge) und 4 unklare Todesfälle. In 30 von 34 Fällen war die Todesursache zweifelsfrei zu klären. In allen Fällen bildete das rechtsmedizinische Gutachten eine adäquate Entscheidungsgrundlage für die Ermittlungsbehörden, wobei insbesondere die Klärung eines Kausalzusammenhangs zwischen bei der Leichenschau festgestellten Verletzungen und dem Todeseintritt von Bedeutung war. Die Ermittlungsverfahren wurden ausnahmslos eingestellt.SummaryAutopsies from 34 fatalities in nursing homes covering a 10-year period (1991–2000) were retrospectively analyzed with regard to criminal investigative issues, causes of death and relevance of the forensic medical findings for the outcome of the criminal investigations. The material consisted of 22 females and 12 males, with the ages ranging from 62 to 102. The allegations to be investigated comprised wrongful death, improper nursing, medical maltreatment, suspicion of poisoning and the causal relationship between falls and the occurrence of death. The manner of death, respectively cause of death encountered included 21 deaths from natural cause (coronary insufficiency, pneumonia), 9 accidental deaths (hypothermia, choking, scalding burns and injuries due to fall) and 4 cases which remained undetermined. In 30 out of 34 cases, the cause of death was unequivocally established. In every case, the medicolegal investigation provided adequate evidence for the legal assessment. Of particular significance was the exclusion of a causal relationship between falls and the occurrence of death. Without exception, all investigations failed to uncover criminal causes for death in this sample.

A novel experimental approach for classifying blood trails in relation to three different speeds of movement

PurposeWhen leaving axa0crime scene, bloodstained victims or offenders typically leave bloodstain patterns with axa0characteristic distribution and shape determined by the direction and speed of travel. The primary aim of this study was to examine whether shape and size characteristics of bloodstain patterns provide axa0method to accurately classify speed and arm movement.Material and methodsIn this study five subjects experimentally generated blood trails while moving over axa0distance of 10u2009m with axa0blood source mounted on the right arm. Axa0tear-resistant paper placed on the ground captured the blood pattern. The subjects travelled this distance at three speeds (walking, jogging and running) and with two different associated arm movements (swinging arm versus non-swinging arm).ResultsBy simple visual inspection characteristic geometric bloodstain pattern were identified: When moving slowly with axa0swinging arm, loop-like drip patterns, loops, were created. In contrast, slow movement with axa0non-swinging arm resulted in patterns resembling waves. The length and width of the loops and waves significantly increased in correlation with the step length (cm) and speed of motion (m/s). When analysis was limited to walking and running experiments, axa0significant, correct classification was achieved in 89% by including length and width (cm) of the loops and waves in axa0derived discrimination function. Axa0new discriminant formula for differentiating between blood trails caused by walking and running movement is presented.ConclusionThe analysis of the distribution and dimension of loop and wave-like drip patterns, including the speed of movement and biomechanical properties (i.u2009e. arm movement) can greatly contribute to professional crime scene reconstruction.ZusammenfassungHintergrundBlutende Opfer oder blutbehaftete Personen hinterlassen beim Fortbewegen, bzw. beim Verlassen von Tatorten Blutspuren in Form von Tropfspuren, deren Form und Verteilung mögliche Rückschlüsse auf die jeweilige Bewegungsgeschwindigkeit und Bewegungsrichtung gestatten. Primäres Ziel dieser Studie war es zu prüfen, ob die Form- und Größeneigenschaften von Blutspurenmustern sich dafür eigenen, Geschwindigkeit und Armbewegungen exakt zu klassifizieren.MethodenFünf Probanden erzeugten jeweils auf einer mit Papier ausgelegten Laufstrecke von 10u2009m geschwindigkeits- und bewegungsabhängige Tropfpfade. Die blutende Verletzung wurde durch eine am rechten Arm angebrachte, artifizielle Blutungsquelle imitiert. Die Probanden legten die Laufstrecke in drei Bewegungsgeschwindigkeiten (Gehen, Joggen und Rennen) und mit jeweils zwei bewegungsassoziierten Armpendelbewegungen (frei schwingender Arm/festgehaltener Arm) zurück.ErgebnisseBereits visuell konnte eine geometrische Unterscheidung der Spurenbilder in „loops“ und „waves“ erfolgen, wobei „loops“ bei einem schwingenden Arm und „waves“ bei einem festgehaltenen Arm erzeugt wurden. Sowohl die Länge (cm), als auch die Breite (cm) der „loops“ und „waves“ nahm in Abhängigkeit von der Schrittlänge (cm) und Geschwindigkeit (m/s) zu (pxa0< 0,001). In 89u2009% der Fälle konnte eine signifikante Klassifikation der Spurenbilder anhand der Länge und Breite (cm) in die Geschwindigkeitsklassen „Gehen“ und „Rennen“ erfolgen. Wir präsentieren eine Diskriminanzfunktion zur Einteilung der Spurenbilder in „Gehen“ und „Rennen“.SchlussfolgerungKönnte eine Tropfspur mögliche Rückschlüsse auf die Bewegungsgeschwindigkeit geben, empfiehlt sich im praktischen Alltag die Vermessung von Länge und Breite der Spurenbilder. Unter Voraussetzung entsprechender Blutspurenmuster kann dann einen Schätzung der Bewegungsgeschwindigkeit erfolgen.

Akute Lungenthrombembolie@@@Acute pulmonary embolism: Begutachtung von Diagnose- und Behandlungsfehlervorwürfen@@@Forensic assessment of accusations of diagnostic and treatment errors

ZusammenfassungDie akute Lungenthrombembolie (LE) ist eine lebensbedrohliche Erkrankung, deren unverzügliche korrekte Diagnose und Therapieeinleitung die Prognose der betroffenen Patienten entscheidend verbessert. Vorwürfe ärztlicher Behandlungsfehler betreffen hierbei nicht nur ein mögliches Nichterkennen der LE, sondern überdies auch nachfolgende Diagnoseschritte, gewählte Therapieverfahren und mögliche Fehlmedikationen. Aus rechtsmedizinisch-gutachterlicher Sicht ermöglichen die klassische Symptomenkonstellation sowie seit langer Zeit etablierte und international anerkannte standardisierte Diagnosealgorithmen und Therapieverfahren die fundierte Einschätzung der Behandlung eines solchen Patienten. Notwendige Schlüsse zur Beurteilung eines etwaigen Behandlungsfehlers können aus dieser Einschätzung abgeleitet werden. In Fällen ohne Ausprägung klassischer Symptome sind hingegen Differenzialdiagnosen der LE einzubeziehen. Die vorliegende Arbeit versetzt den (rechts-)medizinischen Gutachter in die Lage, anhand der aktuellen medizinischen Literatur die evidenzbasierte Bewertung eines konkreten Einzelfalls vorzunehmen und somit zur Objektivierung der rechtsmedizinischen Expertise beizutragen.AbstractAcute pulmonary embolism (PE), e.g. following deep vein thrombosis, is a life-threatening incident. Immediate correct diagnosis of the disease with subsequent initiation of the correct therapy regimen is crucial for the prognosis of affected patients. Allegations of medical malpractice may not only concern missed diagnoses but also initial diagnostic efforts and initiation of a specific therapy. In forensic casework a classical set of symptoms as well as well established and durable diagnostic algorithms and therapy regimen enable the forensic expert to reliably assess the quality of treatment in a given case and derive the necessary conclusions to refute or substantiate a suspected case of medical malpractice. This publication is intended to enable the forensic expert to assess the diagnostic and therapeutic approaches in cases of clinically suspected and autoptically proven acute pulmonary embolism following deep vein thrombosis on the basis of current medical research. Thus it may serve to further implement and strengthen evidence-based aspects in forensic casework.

Pneumonie@@@Pneumonia: Begutachtung von Diagnose- und Behandlungsfehlervorwürfen@@@Forensic assessment of accusations of diagnostic and treatment errors

ZusammenfassungDie Pneumonie ist eine Erkrankung mit allgemein zunehmender Inzidenz und zählt zu den häufigsten Komplikationen von Krankenhaus- sowie Pflegeheimaufenthalten mit erheblicher klinischer, forensischer, gesundheitspolitischer und volkswirtschaftlicher Relevanz. Bei der forensischen Begutachtung von Behandlungsfehlervorwürfen im Zusammenhang mit Pneumonien kann der Gutachter auf qualitativ weit entwickelte Empfehlungen der Fachgesellschaften (S3-Leitlinien) zu Diagnostik und Therapie dieser Erkrankung zurückgreifen. Leitlinien sind als Handlungskorridore zu begreifen, von denen in berechtigten Fällen abgewichen werden kann. Im Prozess einer Begutachtung können sie als Kontrollinstanzen der Argumentation des Sachverständigen fungieren sowie die sachlich-fachliche Korrektheit und die Standardisierung des Gutachtens unterstützen. Belastbare epidemiologische Daten zu Morbidität und Mortalität sowie evidenzbasierte Studien zu häufigen Erregerspektren, Diagnoseverfahren und Therapieoptionen der Pneumonie verdeutlichen, dass dem standardisierten und gewissenhaft dokumentierten, zugleich individualisierten ärztlichen Risikomanagement eine entscheidende Bedeutung bei der Wahl diagnostischer und therapeutischer Entscheidungen zukommt. Eine Unterscheidung zwischen ambulant erworbener („community-acquired pneumonia“, CAP) und nosokomialer Pneumonie („hospital-acquired pneumonia“, HAP) in der gutachterlichen Bewertung ist empfehlenswert, da sich die Anforderungen an das beteiligte und somit verantwortliche medizinische Personal in Abhängigkeit von dieser Klassifikation erheblich voneinander unterscheiden können. Nach den Ergebnissen der Recherchen in dieser Übersichtsarbeit wird eine strukturierte gutachterliche Bearbeitung getrennt nach den einzelnen Vignetten „Diagnose-“, „Therapie-“ oder „Organisations- und Strukturfehler“ empfohlen. Diese nachvollziehbare Unterteilung kann auch Defizite sichtbar machen, die außerhalb eines medizinischen Entscheidungskorridors liegen. Dem forensischen Sachverständigen kommt die Aufgabe zu, den konkreten Einzelfall zu begutachten und die Beurteilung durch wissenschaftliche Belege aus existierender (verfügbarer), valider (gültiger), aktueller und brauchbarer (praktikabler) Evidenz zu stützen. Das zunehmend stratifizierte und komplexe Wissen zum Thema Pneumonie macht exemplarisch deutlich, dass der rechtsmedizinische Sachverständige auf fachspezifisches Expertenwissen angewiesen sein kann und häufiger auf dieses zurückgreifen sollte.AbstractPneumonia is a medical entity with currently increasing incidence and has become a major issue in public and private health systems especially as a complication of patients in hospitals and nursing homes. In cases of (fatal) pneumonia with allegations of medical malpractice the forensic expert can rely on precise and well-developed guidelines from different medical associations (S3 level) concerning diagnostic and therapeutic aspects of the disease. Guidelines can serve as control mechanisms for the line of arguments within an expert statement and enhance the scientific accuracy. Furthermore, these guidelines guarantee a certain degree of standardization within a given group of experts. Authoritative epidemiological data concerning morbidity and mortality as well as evidence-based studies have elucidated different spectra of pathogens, diagnostic and therapeutic approaches. These data have demonstrated that a standardized and diligently documented but still individualized risk assessment is crucial for the choice of diagnostic and therapeutic options. Community-acquired (CAP) and hospital-acquired pneumonia (HAP) should be differentiated in the subsequent forensic expertise as differing hygienic and diagnostic requirements will result from this differentiation. A structured forensic expertise with partitions broaching the issues of diagnostic, therapeutic, work organization-related and structural medical malpractice is suggested to enable the expert to identify potential malpractice aspects which are not usually attributable to the responsibility of the accused physician. The forensic expert is confronted with the problem of assessing an individual case on the basis of current scientific evidence which has to be available, reliable, valid, and suitable for the case. Pneumonia as a medical entity with very complex and stratified algorithms concerning diagnostic and therapeutic aspects serves as an ideal example to demonstrate that even with detailed knowledge of the medical literature forensic experts needs to rely on subject-specific experts for a conclusive expertise.