Polaroids are generally user-friendly and can be good for investigations but must

get Polaroid Spectra law enforcement camera (approx. $250) or top-of-line

Polaroid ($800).

2. RULE OF THIRDS

V/hen taking pictures ofinjuries:

First picture should be of subject, ie take head — to —toe picture of individual

V at4—Sfeet.

• Second picture should be closer, focus a little more on area of body where

V injury is present.

• Third picture should be close up of injury; use ruler or other scale for

measurement purposes. Ifruler or scale covers area of body, also take picture

• without the ruler. V

3.FILM

V

V V

Need to use a film with a fast speed. Often difficult to get elderly or DD

population to stay still long enough for a good picture. Fast film speed will

reduce distortion from movement. ISO 400 15 good all-purpose film speed.

Use 12 exposure film for photographing most injuries. One filmlpatient. Don’t

use leftover pictures for personal use; could compromise professionalism. Better

to take leftover pictures of facility or site or just rewind film without using all of

the film. If you knoW that you will be photographing site and subject, may want

to get 24 exposure. - 4. MEASUREMENTS V

Always have a ruler and tape measure. Get ruler that is plain, no advertisement.

Tape measure can help to measure items in a resident’s room (ie determine if bruise

on leg is at the same height as a table in the room and therefore could explain the

injury).

Use right angle scales/rulers for bite wounds. Forensic dentists can re-create bite

V pattern. ME offices know of forensic dentists.
35mm with fixed focus are of no forensic usefulness. Need to have one that has

interchangeable lenses that can focus for close-ups.

5. LIGHTiNG

If pictures are taken under a flourescent light, they will have a more greenish tint than actual color. Try to take pictures in area without flourescent light.

6. DIGITAL CAMERAS

Biggest problem with digital cameras is that photos can be altered, manipulated,

enhanced.

If using one, it should be at least 3.something megapixels.

The CD ROM becomes the master negative. Always immediately make a copy ofthe master negative. Leave the masternegativeuntouched. Use the copy of

enhancements, printing, etc. In report, explain the software used to make

changes, enhancements and explain exactly what types of changes were made.

You are representing that the picture is a true and accurate representation of what

• you saw. Not necessarily wrong to enhance photo to represent more accurately

what you saw but always record exactly what enhancements were made and have

V master negative available in original form.

6. CHAIN OF CUSTODY

V

Chain of custody offilm or camera is important, especially with digital since the

images can be altered.. Ask local police where they take film to be developed. If you

go to Wal-Mart type store for developing, make sure that developers know this is

evidence for law enforcement purposes.

Chain of confidentiality: must be maintained by medical professionals for medical

pictures,ie Xrays, MPJ images, labs, etc. Also, photos may be taken as part of diagnosis and treatment. Medical professionals don’t need to maintain chain ofcustody but do need to maintain a chain of confidentiality.
For individual who is competent, say 

y

j

picture”, then dD it. If individual is not competent, say same to family or

guardian. Ifrefuse to consent, use body maps.

8. LABELING PHOTOS

Use Avery laser gum labels (2” x 4”).

Each label should contain the following information:

Client name

Client number

Client DOB

Date and time of photo

Name ofphotographerPhysical location and body part location

Label should be placed on the back of the photograph. Do not write on whitebottom border of Polaroid picture, especially when picture is still developing.

The white part contains the chemicals needed for developing the picture. Writing

on it can distort the picture.

9. LOOKING FOR AND PHOTOGRAPHING INJURIES

To try to determine where injuries are, sometimes have to rephrase questions in order

to get response: To find out ifsomeone is abusing resident, should ask in a number of

ways: “is someone abusing you?” “is someone hitting you?” “is someone hurting

you?” Individual may respond “no” to one or more of those questions but “yes” to

one. What is happening to the individual and the response to the questions is

dependent on that in divi dual’s perspective/understanding.

Strangulation injuries: often not visible or can be easily hidden under clothing/hair.

Defensive posture injuries: bruises/lacerations/cuts, etc . to the forearm

Hair pulling: very effective way to control people. Can cause neck/spinal injuries,

alopecia. To demonstrate albpecia, comb through hair, take picture of comb with hair

next to resident’s face.

Injury with central clearing: individual is hit so hard and with such force that theblood explodes sideways; point of impact is blanched or whitened while dark, bruised

areas appear around the point ofimpact.

abrasions to back indicate dragging along a rough surface).

An abrasion will have debris in the injury after incident that will give clues. This

is called trace physical evidence. Nurses usually fail to document what’s found in

the, abrasion and often clean the wound without looking or documenting what’s in

the abrasion. Trace physical evidence will give clues as to how and where the

person received abrasion, ie carpet fibers, dirt, concrete.

Fall down vs. found down: iffall is unwitnessed, nursing staff may document that

resident fell down when in fact resident was “found” down. There is a need to

‘clarify the nursing notes when it states resident down to determine ifthe

‘fall’ was witnessed or ifthe resident was actually “found’ down. If the resident

is found down, there is the need to try to determine how the resident got to the

ground. - Avulsion: the tearing (chunking) away of a structure or part. Often seen as a partial

avulsion. Example of avulsion is a skin tear. A skin tear results from blunt or

shearing force trauma. Often, it may be accidental but look at all circumstances

(ie CNA fmds out she will have to work the weekend, is an-y, goes to bathe

resident while still angry, scrubs a little too hard, causes skin tear).

Bruise: blunt force trauma that results in a superficial discoloration due to hemorrhage

into the tissue from ruptured blood vessels from beneath the skin surface without..

the skin itself being broken. Also called a contusion.

An individual may have an abrasion, avulsion and bruise in one injury but it is

rarely documented that way. An investigator needs to ask whether any or all are

present because each gives clues as to how the injury occurred.

Contusion: a bruise. Traumatic injury of tissue without breakage of skin. Blood

accumulates in the surrounding tissue producing pain, swelling, tendemess, and

discoloration.,

Discoloration process: 1. red

2. black andblue

3. blue-green

4. green-brown

5. brown-yellow

6. yellow to fade
is trauma to the central or midline parts of the body. Proximal injuries are easier

to conceal under clothing and therefore, such injuries are more likely to be present in abusive situations.

Ecchymosis: a hemorrhagic spot or blotch, larger than petechia, in the skin or mucous

membrane forming a non-elevated (no swelling), rounded or irregular blue or

purplish purpuric patch.

This term is misused by medical and non-medical staff 9 times out of 10. It is

often misused as a synonym for a bruise or contusion. Ecchymosis is usually not

an injury from blunt force trauma. It is often from spontaneous oozes that can

occur in the elderly. In the elderly, it is found most often on arms and hands.

However, ecchymosis and bruising can result from a leak from another part of the body that has suffered trauma, ie if an individual is hit between the eyes, hemorrhaging will not appear on the area that suffered the trauma but it will

appear around the eyes.

Certain medications can put an individual at greater risk for bruising and ecchymosis: aspirin (antiplatelet), warfarin (coumadin, anticoagulant), ibuprofen and ketorolac (NSAIDs), heparin (anticoagulant), vaiproic. acid and depakote (thrombocytopenia), prednisone (steroids).

Routine handling of patients taking these meds can result in bruising. Ifthere is

significant bruising, the individual should have blood labs drawn right away. Labs can provide clues on the source ofthe bruising. Compare labs to baseline

lab draws (pre-injury). The labs should include:. CBC with platelets; basic

chemistries (CHEM - 7, albumin, BUN/creatinine); liver function (a bad liver will

promote bleeding); coagulation panel (PT/PTT); urinalysis.

Certain supplements can put an individual at greater risk for bruising and

ecchymosis: herbals (over 40 herbs can affect bleeding), bilberry (may prolong coagulation times), garlic (reduces coagulation), ginger (increases risk of bleeding when used concurrently with anticoagulants, bilberry, or aspiin), gimko (increases risk of bleeding when used concurrently with anticoaulants or bilberry).

Incision: a cut; a wound made by a shar instrument or object, ie scalpel, knife, paper..
injury, or certain which object caused the injury and/or by what mechanism an injury was

caused. Glove bums or sock bums are examples. Glove bums occur when hand is

immersed in hot water. Sock bums when foot is immersed in hot water.

Pattern of injury: Injuries in various stages of healing, including new and old scars,

contusions, fractures, wounds.

Petechia: minute, pinpoint, non-raised, perfectly round, purplish-red purpuric spot

caused by intradermal or sub-mucous hemorrhage, which later turn blue and yellow.

(Plural is petechiae; adjective is petechial).

Strangulation (not choking) is most common cause of petechia. There are 3 types

ofstrangulation: 1) Manual: hands or headlock used arOund neck; 2) Ligature:

something is tied around the neck, usually leaves a mark; 3) Mechanical: example is

when head is wedged into something.

Other causes ofpetechia

1. Labor and delivery of baby;

2. Severe vomiting or coughing;

3. Sneezing;4. Constipation, straining duing BM

Petechia occurs when there is no blood to the brain (anoxia). The capillaries burst

causing the spots (blood builds up because carotids are blocked).

Puncture: the act ofpiercing or penetrating with a pointed object or instrument.

Purpura: a hemorrhagic rash with leakage of blOod into the tissue often associated with

a bleeding or clotting disorder. Diffuse purpura under the skin or mucous membrane iseccbymoses while pinpoint purpura is petechiae.Wound: A bodily injury caused by physical means, with disruption ofthe normal

structures.

Contused wound - one which skin 5 unbroken

Incised wound -one caused by cutting instrumentLacerated wound - one in which tissues are torn

Open wound - one having free outward opening

Penetrating wound - one caused by a sharp, slender object that passes through the

skin into tissue V