Notes On Legal Medicine (FINALS)

Notes on Legal Medicine
June 21
Legal medicine (AKA forensic medicine) branch of medicine that deals with application of knowledge to legal problems and proceedings
Medical jurisprudence - branch of law that deals with application of law to medicine or conversely medical science to legal problems
Forensics application of scientific knowledge to legal problems and proceedings - Used in the pursuit of justice in court proceedings and in the protection of the public from environmental hazards
Pathology branch of medicine that deals with diagnosis of disease and causes of death by means of laboratory exams of body fluids, cell samples and tissues from the body. if alive = biopsy if dead = autopsy; systematic external and internal examination of the dead a subspecialty is forensic pathology: a forensic pathologist examines persons who died suddenly, unexpectedly, violently or a medically unattended death, an expert in determining the cause and manner of death, involved in crime investigation, case coordinator for the medical, forensic and scientific assessment of a given death (may be the lead investigator), expert in interpreting the scene of death, assessing the consistency of witnesses and interpretation of pattern injuries
Medico-Legal officer physician who is involved in medico-legal duties SEC. 95 Code of Sanitation: Any medical officer (MHO, RHO, District Health Officer), medical offices from law enforcement agencies, CHR and members of the medical staff of accredited hospitals. Medico-legal cases: deaths or injuries involving persons who have no means of being identified, those who are pronounced dead on arrival on ERs, deaths under the following circumstances [death occurred within 24 hours of admission, clinical cause of death is unknown, unexpected sudden death especially when the person was of apparent good health, d/t natural disease but associated with physical evidence of foul play, death as a result of violence, suicide or poisoning, death d/t negligence of a 3 rd person, including cases of child abuse, physical and sexual abuse, rape, drug addiction and iatrogenic causes of injury, disease or death (one caused by the medical professional such as the doctor/nurse), etc]
Child protection specialist - new kind of specialist in the field of pediatrics; deals with medico-legal cases of children who were allegedly abused
NO formal training on how one becomes a Medico-legal officer. Page 1 of 37

Doctor as a witness: Can either be a professional witness or an ordinary/ fact witness or both Give factual medical evidence, cannot give comments or opinions BUT an expert witness can give an opinion about medical facts Expert witness has special knowledge as well as current knowledge or skill gained by education, training, or experience in the field of expertise Explain scientific matters that may or may not be understood by judges Medical expert testimony could either be for the prosecution or for the defense Medical testimony must be objective and accurate Law does not make a qualification of an expert physician based on a medical specialist (so look into their qualifications, their formal training etc)
Child Protection has set qualifications of a doctor who can provide care for the sexually abused child and these are doctors who can also give expert testimony in court. 1. pediatrician, gynecologist, pediatric gynecologist, family (important that theres exposure to children) 2. formal training 3. updated with research studies 4. experience 5. regular conference, consult one another here and abroad etc medicine
Pre-trial preparation of the expert witness refreshes the level of expertise, enhances quality of opinion expressed and saves time. Lawyers must also be prepared in their questioning.
Permit the witness to explain and LISTEN.
Know the value of the medical literature presented. When it comes to research the best level of evidence is a blind test that is random.
Protect your witness. Do not allow your witness to be harassed by the other side. If its a child witness know the rules in examination of a child witness.
What you should not do: 1. 2. 3. 4. ask a question you do not already know the answer do not quarrel with the witness ask clear questions Allow witness to explain his answer. An expert witness has a right to explain. 5. do not ask long and complex questions especially with children 6. do not ask absolute questions (always, never etc) nor use unnecessary adjectives June 28 Page 2 of 37
DEATH A person is alive because of the 3 main parts of the body: 1. The brain; 2. The respiratory center; and 3. The circulatory center You heart pumps blood throughout the body to circulate oxygenated blood. These are the two most important systems: your cardiac and circulatory system and respiratory system that will keep you alive, and the main center for control is the brain. Definition of death: The cessation of life in a previously living organism. It is a process, not a single event.
Medical and legal status of death: o Medical Doctor proclaims or pronounces a person dead. o Legal Extinction of the persons identity, etc. The ascertainment of death is a chemical problem. Its the doctor who will determine when a person has died. Stages of Death: 1. Clinical or somatic death 2. Brain death 3. Biological death 4. Cellular death Clinical or somatic death: The respiratory and circulatory functions have ceased. But because of an advancement in medicine, the circulatory and respiratory functions may be restored through resuscitating measures. You may end up as a person whos wide awake, continuously breathing, heart still beating. Or you may end up as a person whos awake, heart beating, but youre not breathing on your own. Or you may end up as a person whos just out. You are unconscious and cannot communicate with your environment. Youre breathing, either on your own with your heart beating on your own, or your respiration is being assisted, with your heart beating on its own. If theres irreversible unconsciousness, with spontaneous respiration and heart beat, it cannot be accepted as true death. The person is still breathing on his own. Hes unconscious but hes breathing on his own, his heart beating. Brain death: If the brain does not receive oxygenated blood within 3-7 minutes, your heart stops beating. Neurons die if theres no oxygen brought to the brain within 7 minutes. Brain death follows a stage: 1. The cerebral cortex or that part of the brain with higher functions die first. 2. The cerebellum (the part of the brain thats for keeping your balance and coordination) follows. 3. The last to go is the brain stem. It is in the brain stem where the cardiac and respiratory centers lie. Its the stem brain thats what will keep you alive. Page 3 of 37
So we have what we call a persistent vegetative state. Youre completely unconscious but youre breathing on your own, with your heart beating. Or you may have assisted ventilation. And it is assumed in such a state that the brain itself is functioning. Higher brain centers are dead except for the brain stem. Because the brain stem is not dead yet, the cardiac and respiratory centers are working. So even if youre totally unconscious, you may be breathing on your own and your heart is beating on its own. Or your heart is beating but your are breathing through a ventilator. And the only thing thats needed is to keep feeding the patient. So these are the people we call vegetables. Biological death: Here finally, even the brain stem dies. All components of the brain die, closely followed by cellular death. Cellular death: Think of cells as mini tiny factories. So in cellular death, these factories shut down one by one. And eventually, they would just break up and decay. Cellular death itself also does not happen all at once. Cells die slowly. Because evidence now is showing that, lets say, your skin and bones may remain what you call metabolically active (still alive for many hours). Thats why after death, if you need to transplant or use bones or skin, they may be harvested and cultured up to 12 hours after the heart has ceased beating. Neurons of course die after 3-7 minutes. The heart and kidney can still be used if theyre harvested within 8 hours of cessation, after the person is pronounced death. So its very important, especially when were talking about transplantation. The person must be pronounced dead by the attending physician. So death actually takes a long time. It doesnt mean that just because the person stops breathing and his heart is not beating, hes dead. Its a transfer from one state of viability to another and may be slow or rapid depending on certain factors, like your age. The very young and the very old, they die faster. Very young, because theyre very immature, the very old because of the wear and tear. They dont have defenses anymore so they can die really fast. If youre very thin, if youre malnourished, if you have all these diabetes and heart problems, your death will be faster. Or environmental factors (good thing it doesnt snow here). If youre sickly and its cold outside, youre not wearing anything, or youre malnourished, youre going to die fast. So its the physician who pronounces death when what you call the point of irreversibility has been breached. And when is that? When does a doctor say that the point of irreversibility has been breached? Traditionally, when the doctor doesnt feel a pulse or doesnt hear the heart beating and the person is no longer breathing, we say the person may have died. 1. Other ways of finding out whether that person is really dead is by putting a mirror on the face, at the mouth and nose, of the person. If theres no condensation on that mirror, it means the person is not breathing. 2. What we can do is also look into the eyes, through the pupils. We can see what we call the fundus where you can see the blood vessels. If the blood vessels are not pulsating, that means the heart is no longer beating. We can use EEG (electroencephalogram) test. But in the province, you dont have EEG. The doctor usually uses what you call the ophthalmoscope to look into the eye and check if theres still pulsation. Sometimes, they dont have a mirror, so doctors bring compacts, like the ladies. So its just a pulse or listening to the heartbeat. Page 4 of 37

3. You can also try to monitor response by giving painful stimulation to the patient. One is pressure on the glabella ( N.B. the space between the eyebrows, unless you have a unibrow!), pressure on the sternum, or pinch the finger. So if the person is alive, hes going to drive you away because these are very painful areas. Especially if the person is lying down and youre standing up, and you put so much pressure, that can be very painful. 4. The other ones and very importantly, will be the absence of brain stem reflexes. Meaning the response to pain stimuli in these areas come from the brain stem. If these are absent, that means the brain stem is dead. Corneal reflex what we do is get a wisp of cotton and touch the cornea. You know how painful that is. So a person will blink. If youre dead, you wont feel anything anyway. So a live person will be in pain. Shine light into the pupils if youre dead, your pupils are expected to be dilated. If you shine a light, the pupils should normally constrict. A dead person will not have that reflex anymore. Oculovestibular response we inject ice cold water into the ear. And we normally expect the eyes to move the opposite side. So if the eyes will not move, then theres no reflex. Gag reflex when you put a tube, catheter, or tongue depressor and try to stimulate the back of the throat. Youre going to gag if youre alive. Apnea test (apnea means no respiration at all) this is done mostly on people on ventilators. What is done is, we get what we call arterial blood gases. Essentially, we want to know what the level of oxygen and carbon dioxide is in the blood. So while on the ventilator, oxygen is flowing into the lungs. We get the arterial blood gases then the ventilator is turned off for about 5-10 minutes. After that period of time, arterial blood gases again are taken. If the oxygen level of the blood is very, very lowtheres a certain numberif the carbon dioxide level is very, very high, that is a sign that the patient is not breathing at all. If all of these are not present, then the person is dead. Plus, you can also have a silent EEG where no more brain activity is going on. There are criteria for death. As I said earlier, because of new developments in medicine, a person may not be declared dead immediately. Of course, the first thing that came up was your cardiac pulmonary resuscitation (CPR). But we have other advancements. We have fibrillators. First, when a person suffers from a heart attack, it has been proven that the heart fibrillates. The person faints because the heart fibrillates. How does a heart look like when its fibrillating? Imagine a bag of live worms. You look at the outside. Its just going like that. Instead of pumping blood out, your heart is just going like that when you suffer from heart attack. If you put your stethoscope on the chest, youre not going to hear it so youre going to say hes dead. But applying defibrillators can still revive the heart. Thats why its very importantif any of you witness a person who may be undergoing a heart attackto just have to call the emergency medical services. Here we have ERUF. They have defibrillators just to get your heart to start pumping immediately. Theres what you call for a person who needs a heart transplant. They have what you call assisted devices (not a pacemaker). Its practically there pumping because the heart muscle itself is not pumping, or inadequately pumping. You have you ventilators. These are machines that help you breathe. But we have a problem whereinbecause of modern resuscitation technology, Page 5 of 37

even if all brain functions will have ceased except for the cardiac and respiratory centersyour heart can still be beating, but you may still be connected to a ventilator. So are you going to say that the person is practically dead? The heart is still beating. The brain stem is still alive. Can you say that person is dead? If you discontinue ventilation, is it homicide? Because its very hard to keep this person alive for a long time. It can be physically, emotionally, financially draining. The care there is every hour, every minute. You turn that person to sides and hes not even responding to you. So how does one determine death? Uniform Determination of Death Act defines death as either: irreversible cessation of the circulatory and respiratory functions; or irreversible cessation of functions of the entire brain, including the brain stem. And the determination of death must be made in accordance with accepted medical standards. Harvard Criteria essentially the same definition. a. Unreceptivity and unresponsiveness meaning theres a total unawareness of externally-applied stimuli, pain stimuli, etc. There must be complete unresponsiveness despite application of painful stimuli. b. No spontaneous movement or breathing absence of spontaneous muscular movement or breathing, as well as absence of response to stimuli, such as pain, touch, sight, etc. c. No reflexes d. Confirmation by two EEGs there must be two EEGs taken 24 hours apart. I dont know if you remember this person. This one person was essentially declared dead. Shes breathing on her own, her heart is beating, she was just being fed. But the husband, probably tired of taking care of her, went to court and asked the court to declare her dead, so they just stopped her feeding, and she died of starvation. To me, she does not fall under the Harvard criteria or the Uniform Determination of Death. So lets go to organ and tissue transplantation. In organ transplantation, there are instances when the person must be dead first. If you will look at the Organ Donation Act of 1991, death is defined as: The irreversible cessation of circulatory and respiratory functions or the irreversible cessation of all functions of the entire brain, including the brain stem. A person shall be medically and legally dead if either: (1) In the opinion of the attending physician, based on the acceptable standards of medical practice, there is an absence of natural respiratory and cardiac function and, attempts resuscitation would not be successful in restoring those functions. In this case, death shall be deemed to have occurred at the time these function ceased ; or (2) In the opinion of the consulting physician, concurred in by the attending physician, that on the basis of acceptable standards of medical practice, there is an irreversible cessation of all brain functions; and considering the absence of such functions, furthers attempts at resuscitation or continued supportive maintenance would not be successful in restoring such natural functions. In this case, death shall be deemed to have occurred at the time when these conditions first appeared. Page 6 of 37

The death of the person shall be determined in accordance with the acceptable standards of medical practice and shall be diagnosed separately by the attending physician and another consulting physician, both of whom must be appropriately qualified and suitably experienced in the care of such patients. The death shall be recorded in the patient's medical record. So the attending physician may call another consultant; he and the attending physician can be the ones to declare a person dead. Now going to problems regarding transplantation, the problems are consent and authorizationwho will consent or authorize to donate organs, who will determine death in case of procurement from a cadaver. And there is a problem of rationing organs, theres not enough organs for transplantation. More so in the US and Europe where they do a lot of organ transplantation. So here for us, a person who may execute or authorize to have a part of his body donated is anyone above 18. In the US, there in their drivers license, its indicated if you want to donate your body or a part of your body, and automatically, youll be sent to the hospital and the hospital will harvest your organs. Of it could be anybody somebody of legal age can sign for you. Your parents, siblings, or guardian. And the organs have to be harvested within 8 hours. So you have to consider the time to remove, travel time, time to operate the recipient, etc., so you have to make the decision fast. Manner of executing a donation: The death of a person from whose body an organ will be removed after its death for the purpose of transportation to a living person, shall be diagnosed separately and certified by 2 qualified physicians, neither of who should be a member of the recipient team. The surgeon who will be the one to remove the organ cannot be the people who will declare that person dead, etc. Its conflict of interest. It should only be the attending physician. Sources of organs: o Fetus contains cells which we call stem cells. They contain cells that have the potential to become any kind of tissue, provided that tissue is placed in the right environment. So if you put a tissue in the area of the heart, that tissue will develop into heart cells. Anencephaly infants are babies born with only the brain stem intact. They dont have a skull cap, they dont have the higher brains, but just the tiny brain stem. Thats why theyre alive, they have all those reflexes, theyre breathing except for that abnormal head. But when they die, their hearts can be used for transplanting to babies with congenital heart diseases. o Artificial animal transplants The problem here is, its not matching. I dont know how compatible you can be with a pig or a cow. And the problem there also is, that animal may have some kind of disease which the human never gets. Whats going to happen is, its passed on to the human being who received the disease from the pigs heart. So how are you going to cure that illness? We do have problems with using animal tissue, although the Philippine Heart Center used to transplant pigs heart valves, etc. into heart valves of patients but theyve stopped. Homologous transplantation when tissue is removed from one part of the body and put back into your own body. So you scrape skin from your thigh, probably to cover a burned area in your back. Or you chip part of your pelvis and transplant it to an area where theres a bad fracture, for that fracture to heal faster. Or in cases of Jehovahs Witnesses, who cannot accept blood from any other person. I had an experience where a patient had to undergo an open heart surgery. (For those who undergo open heart Page 7 of 37

surgery, you heart has to stop beating.) So the blood must go through a cardio-pulmonary bypass machine and then returned back to your heart, bypassing the heart and lungs. So in this case, its the patients own blood thats circulating, diluted with IV fluids. Your tissue is taken from a living donor and these tissues will be matched first with a recipient. If youre compatible, your blood can be extracted and transfused to another person. Theres what you call bone marrow transfusion, for patients with leukemia with white blood cell problems. There are also people who will donate their own kidneys for a fee. But bear in mind the Anti-Trafficking in Persons Act 2003, Sec. 4., wherein youre not allowed to sell your organs. Now, cadaver donation is actually the major source of all tissues for transplantation. So your drivers license may indicate that you want to donate an organ or everything. Most of organs for transplantation come from dead people but they must be harvested soon after the patient is declared dead. o Cloning if you have problems, theyll just give you your clone.
o o
July 5 When everybody dies changes can happen. How do we estimate the time of death? EARLY CHANGES THAT HAPPEN AFTER DEATH: 1. Rigor Mortis 2. CadavericRigidity 3. Post Mortem Hypostasis 4. Cooling of the body after death or Algor Mortis When the heart stops and the breathing stops eventually theres a falling blood pressure, theres no more oxygen and the cell method will stop working and because of that your nerve cells will die and theres going to be no more neurological activity. When blood pressure falls down and theres no more circulation, you would become pale. There would be pallor personae, there will be eye changes, reflex is gone, the pupils will not dilate and will not constrict if its shown light, the blood vessels in the fundus that you see that are actually retina. You wont see any pulsation and if you touch the eye, its very soft. Muscles will become flaccid. As soon as there is a loss of the muscle tone it becomes flaccid and this is termed the primary flaccidity and this may retain any activity and may respond to other forms of stimuli thats why you might see some twitching of the toes or some muscle twitching thats reacting to the stimuli. Its not actually dictated by higher senses. There will also be loss of muscle tone so your anal sphincter will just come out. Your urinary sphincter, your urine will just come out. Or some semen might just be emitted but that doesnt mean that he had just had sex before he died. There will be revegitate of the gastric contents because there is a sphincter in the esophagus and in the stomach. That will also be relaxed so when the person falls on his back or even head down stomach opening relaxes, gastric sphincter will flow backwards this can be confused as if the person died because of asphyxiation (gastric contents going into the airway). The only way we can say that a person died because of asphyxiation from aspirating food is from eyewitnesses account. If food debris can be found down to the smallest part of the lung and then we can say he asphyrated and that is the cause of his death. Rigor mortis. The temperature dependent physico-chemical changes chemical reactions occur within motor cells as a result of lack of oxygen. or
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Difference between a normal metabolic pathway and the anoxic (no oxygen pathway). A normal metabolic pathway happens within your body, within your system. An important reproduction of energy in your body, your ATP using oxygen. So if there is no more oxygen its just glucose that is being used to produce ATP but then without oxygen it will not go through this process of oxidity >>>> lactic acid pathway and will produce a lot of lactic acid in the body. With the lack of oxygen, very little ATP or energy, more of lactic acid what happens is>>>Your muscles are made up of fibers of cells-acti enmycin fibers. They bind together and they form a gel and that makes the muscles stiff. Its that lactic acid that will cause your muscles to gel up thus become stiff. And this can develop fast especially if theres no blood in the >>>> levels. Especially during exercise or when the acidic levels are high or when somebody is stressed or during electrocution when the muscle will be repetitively stimulated, the muscles will keep flexing and flexing, the oxygen levels can be low, glycogen or glucose levels can be low, it will become acidic so rigor mortis can be very fast. It may not be detected in people who have low muscle bulk. Theres not much muscle. So whats there to harden? It is usually detectable first around the eyes and around the jaws and fingers and it will develop from the head down, from the smaller muscle down to the larger muscle groups. In determining the presence or absence of rigor mortis, it is only estimating the time of death. Rigor mortis is a variable process because it can be affected by a lot of environmental factors. It is unreliable to find out the time when the person died. If the person is exposed to a cold temperature he will develop rigor mortis longer as compared to a person who is in a warmer temperature which will be of shorter duration. In temperate conditions its first detected in the face between 1 to 4 hours after death, in the limbs between 4 to 6 hours after death, the strength of rigor will increase in the legs 6 to 12 hours. After that, when cellular metabolism or decomposition of the cells begin, the muscles now will lose its cohesiveness, its gel-like property now will get lost. In this stage of rigor mortis, the body ends enters the stage of secondary flaccidity which occurs between 24 to 50 hours after death. Two types of rigor mortis: primary flaccidity within 24 hours, it becomes stiff; after that the stiffness is gone and thats called secondary flaccidity. One can test for rigors. If a joint is flexed at death, apply some pressure. If it jerks back, that means theres rigidity. If the body feels warm and is flaccid, it may have been dead for less than 3 hours. If it is warm but stiff, it may have been dead for 3 to 8 hours. When the body is cold and stiff, it may have been dead for 36 hours. If it is cold and flaccid up to secondary flaccidity, therefore, more than 36 hours. Cadaveric rigidity. Another term for this is instantaneous rigor or captalictic rigidity. This is based on certain findings wherein some people die holding grass in their hands or holding a gun when he died. Most likely the mechanism behind has something to do with a neurogenic kind of activity when that person is highly stressed at the time of death. Forensically, if a person dies and is found in the water and holding on to something like a grass found outside of that body of water then that person was alive before he was found in the water. Or that person may be holding something that belongs to the alleged perpetrator or whoever was with that person last may be holding on to something. Post mortem hypostasis. At death, circulation stops, all muscles relax, including the muscles in the blood vessels. With the relaxation of the muscle tone in your blood vessels, the blood will settle down in areas where the blood vessels are dependent. The blood has cells and fluid. The passive settling of the blood cells under the influence of gravitiy to the blood vessels in the lowest area of the body. This is forensically important. It is not always seen in the body. It may be absent in the young or in the old, those who are anemic. It may >>>> by that skin colors, jaundice or yellowish coloring of the skin. It mostly forms on the back, buttocks sides, and back of the neck because usually when a person dies hes Page 9 of 37

lying flat on his back but there are some areas of that persons back that could be so pressed on a certain part, like on the bed. A person died on his back so the buttocks probably pressed on the bed will have >>>> called blanching. Meaning, the blood vessels have been squeezed, so blood vessels could settle in this area. The part of the butt not in contact with the bed may be found to have a post mortem hypostasis. You can tell the persons position when he died. When hes hanging, hypostasis will be on the lower extremities not in the torso. Gravity. If the body fall head first, the hypostasis will be in the upper part of the body as compared to the lower part of the body. There may be some changes in the color after death. If the color changes in a cherry pink color, most likely that person died of carbon monoxide poisoning; dark red, by poisoning; bronze, infection caused by an organism called >>>>. If the body was moved and hypostasis is already happening, there could be layering of that hypostasis. Algor Mortis. The body will take on the temperature of the environment. It is useful indicator of the time of death during the first 24 hours post mortem. The use of body temperature as estimation applies only to cool and temperate climates not much in tropical areas because the cooling of our body will not be as much because our environment is warm. Its best measured using core temperature like rectal temperature taken at examination or on discovery. Using oral temperature is not advisable. Examining gastric contents at the time of death will only tell you what he ate the last time. It is difficult to use this estimation of the time of death. Before, it was believed that our stomach empty into the intestines within one hour. Thats no longer correct. It also depends on the kind of food that you eat. Fatty foods remain longer in the stomach compared to non-fatty food. Another method is looking at the presence of insects in the body. There are some insects that like to feed on the human body. Depending on what stage of the insect. You have to get a forensic entomologist. In other countries, depending on the season, they look at the animal bites. In the winter season, its just the bears that are there in the forest. If its summer, its just the squirrels that are there. It is very important that an examiner gives an estimation of the time of death. There is a bracket probability giving an earliest or latest time which the doctor feels that death must have occurred. Its within a range. Decomposition or putrefaction. Most common root of decomposition of the body after death and early changes may be confused to be signs of violence or trauma. There is liquefaction of soft tissues over a period of time. The earlier the process starts the faster it progresses. In a week or so the body cavities will burst and the tissues will liquefy and drain away onto the ground. Mummification. The body cavities dry up and it usually happens in hot or warm environment and also in cold dry areas. Adiposerum. Theres a chemical change in the body fat; the features are retained apparently no decomposition happens. Immersion. It slows down the process of decomposition. A body will decompose in air faster than in water. The most common position of the body in the early stage is, if the chest contains air then the chest is floating and the limbs are hanging in the water so your hypostasis is expected to be in the hands and in the feet. If there are animals in the water, expect also that there will be bites in your hands and feet. If the water is shallow, expect the hands and the feet to be dragging on the river bed. Loss of epidermis first and then there will be gaseous decomposition so that the body will start to float. There could be adiposere formation if the body is under water. When the body is buried it will decay more slowly but if the surrounding is wet, very acidic, the body will decompose faster. Page 10 of 37

Eventually your skin will fall off. Within two years, no more skin tissues, it will then be all skeletal and what will remain will be your tendons, your ligaments, hair and nails. Within five years, nothing is left on the bones and all the joints now will be disarticulated. You can use the bone marrow to get the mytocondreal DNA. Its one way of identifying a person. But the mytocondreal DNA is only that of the mother. Post mortem injuries. It can be determined by looking at the edge of the wound. If you are injured before you died, there will be inflammatory response after your injury. If youre injured after your death, there will be no more inflammatory process that will go on. Embalming. It is a physically invasive process in which special device are implanted and chemicals and techniques are used to give an appearance of restful repose. First the bag is placed on the stainless steel, place the person in table washed with insecticide and germicide and olfactant, the insides of the nose and mouth are swabbed with solution, the muscles are massaged to soften it, creams is placed on the face and then massage so it will look soft. The facial features are set by putting cotton in the nose so its not gonna collapse, putting eye caps below the eyelids so it will not look sunken. Arterial embalming. They inject an embalming fluid into an artery. They inject one gallon or so of a mixture of formaldehyde and other chemicals with water. Chemicals are also injected thru syringe into the other parts of the body. Cavity embalming. The trucar is inserted intto the navel and an instrument is inserted to puncture organs that contain air. Gases and fluids are withdrawn. Fluid is put inside the cavity. The anus and vagina are tucked with gauze to prevent seepage of fluid. Incisions and holes are made in the body, tinatahi, and then the body is washed again. This is the whole embalming process. Exhumation. This is the province of a skilled and experienced forensic pathologist. If the cause of death is poisoning, the pathologist must also get soil samples because there might be fluid in the body that may have seep into the soil or in the coffin and fluid from these areas is best taken to determine if theres any poison present there to determine if the person really died of poisoning. When you exhume a body you have to ask the court, there has to be a court order first. There must be legal reason for exhuming a body.
July 12 DEATH INVESTIGATION.. It involves police investigation and the application of forensic science. Kinds of death that require investigation in the Philippines, understand the principles of death investigation including the autopsy. Learn and understand the contents of a medico legal autopsy report and how the medico legal findings become useful to the legal system. The purpose of death investigation is to identify and develop an understanding of the death of that person. Two types of death investigation: 1. Clinical death investigation happens within the hospital. The doctor or the medical officer or the pathologist wants to know what that person died of, what was the illness, did he die of a certain disease or injuries, or of poisoning. Its just within the hospital setting. Page 11 of 37
2. Medico legal investigation - maybe theres some foul play in the cause of death. It may be that there is a police investigation going on regarding the death of that person. When that natural death occurs, the doctor will sign the death certificate, once the death certificate is signed then the body can be disposed of the, the death certificate will include the cause and manner of death. If the death is natural and no doctor can complete the certificate then that death must be investigated and the death be classified. Death that cannot be examined by the doctor is examined by a variety of legal officers-the medico legal officers or the medical examiners. Herein the country based on the Code of Sanitation, cases where autopsies were performed are those that are required by special laws upon the orders of a competent court, a mayor or provincial or city fiscal upon the written request of police authorities whether the solicitor general or the city or provincial fiscals are authorized by existing laws shall be when necessary to dis>>> and to take possession of the remains for examination to determine the cause of death, whenever the nearest of kins shall request in writing the authorities concerned to a certain cause of death. In order to be autopsied you have to get the consent of the relatives and more often than not they will not consent. If there is foul play you have to run through this people like the city fiscal or the police just to ask for a request for autopsy. And the police authorities wont even ask for the autopsy for the medico legal investigation of the death of the person. These are the problems in our country its very hard to go beyond. It might be that a member of the family killed that person. If somebody is in the hospital and somebody in the room killed that patient, the doctor will wonder how he can die suddenly. Sudden infant deaths. These are the cases that need medico legal investigation. DOAs, people who died and had not been identified, unexpected sudden death especially when the deceased was in an apparent good health, death with natural disease but associated with physical evidence suspicious of foul play, death as a result of violence, accident, suicide, poisoning, death due to the negligent or improper act of another person, deaths of persons whose bodies are too burned. These are deaths that also need medico legal investigation based on the Center for Disease Control in 1998. It includes death which had occurred in custody, these are the types of death that ate not listed in our law that are classified as medico legal cases. A year ago, there were 19 deaths in the BBRC and theres no autopsy that was done. Deaths of persons whose bodies need to be cremated or buried at sea because once you cremate the body you have no more body to exhume. Thats related to disease relating to the employment to or accident on the job, deaths that are related to the disease that might constitute as threat to public health. These are the deaths that are not included in our list. In the US, they have a death investigation team. An author says that death investigation is composed of a coroner, a medical examiner and a forensic autopsy technician (theres no such thing daw, its the embalmer). They have to involve themselves with the people who investigate the scene they also do their own investigation on the backgrounds, conduct examination in the laboratory, they also deal with evidence that consult with concerned parties like the all types of forensic people as well as the police investigators and they must testify in court. In our country, we have a medical examiner, but most often than not it is really the embalmer who does the autopsy. Our medico legal officer will just look at what the embalmer is doing. Doctor Fortun was doing an autopsy on a child and she found something unusual when she feels the rib of the child, theres may be a fracture. She tells the medico legal officer who had autopsied that girl and said feel this out. This is abnormal. The medico legal officer said, he called the embalmer and say, will you please feel that rib if its abnormal or not. The laboratory examinations will have to be done in Manila, the PNP Crime Lab and the NBI Crime Lab. (I dont know and I dont think they obtain evidence, I dont Page 12 of 37

think they even consult with concerned parties but they will testify in court. And I dont know what kind of information they get if theyre only looking at the body. And Im speaking from experience.) Aims of a death investigation: the medico legal officer must find out who died, when that person died, why that person died, and where that person died, and how that person died. The doctor will have to go to the scene together with the police officers. Or a trained pathologist is the best person to investigate this death; he has to get physical and testimonial evidence, photographs and videos and trace evidence, social history, interview the family and the relatives. Get the medical history of that person, medical records from the hospital or medical records from the physician. Medico legal report is important in the process of death investigation. Autopsy is a post mortem examination where the examiner wants to see with his own eyes. Its a scientific investigation of a dead body performed primarily to determine the cause of death and identify the disease that are present. In academic institution these are only for teaching and research purposes. But for forensic autopsies it is to determine whether a given death was an accident, homicide or suicide or a natural event. An autopsy can be performed by any doctor but must be performed ideally by a properly trained pathologist. Our medico legal officer had not had any formal training in doing autopsies. Persons authorized to perform autopsies in our country: The aim is identify the body, estimate the time of death, identify and document the nature and number of injuries. Specific objectives: interpret significance and the effects of the injuries, identify the presence of any natural disease, interpret and identify the significance of the natural disease present, identify the presence of poisons, interpret the effect of any medical or surgical treatment. It is not just looking. It is also analyzing what is seen and has also to see whats not there. Autopsy will consist of an external examination. Examine the whole body on the outside. Collect and trace evidence especially under the nails, on the mouth, etc. After conducting an external examination taking all the necessary pictures and documentation of the injuries including sizes and location of all those injuries an internal examination is done where the body is cut up, each internal organ is removed, weighed and dissected, injuries are looked for, signs of a natural disease are looked for. Anything thats abnormal there are looked for. Part of the autopsy is a laboratory examination wherein tissues, fluids, any weapon fragment bullets or whatever are collected and examined. Autopsy includes gross observations and microscopic examination of all the tissues. That medico legal autopsy must determine the cause of death. Cause of death: It is the disease process or injury responsible for initiating the train of events whether their brief or prolonged using the fatal end results. Its that which starts the event. Mechanism of death: The physiologic or biochemical derangement produced by the above cause which is incompatible with life that is how the disease or the injury leads to death. Manner of death: The fashion or mode in which the cause of death came into being. It may be natural, accident, suicide, homicide, it can be unclassified whether if it is due to alcohol or drug. It could be undetermined. In the homicide classification of death, this is used to classify the kind of death. It is not used to imply criminal intents. Criminal intent is left to the police investigators, into the Page 13 of 37

legal process not in the doctors. It is only used here that the person died because of a volitional act of somebody. Undetermined cause or manner of death it could be like there are so many manners of death that could have happened and its very hard to determine which one weighed more in killing that person. Example: if youre a person who loves to drink a lot of alcohol, eat a lot especially pork, smoke so youre prone to have high blood cholesterol level so you will develop a coronary artery disease. Coronary artery disease can cause two problems in your heart: electrical disturbance and heart failure. Because of the block in your coronary artery theres not enough blood supplying the heart, so it could be that the nerves of your heart or the lethical wires of the heart are not well supplied by blood. So its not going to pump regularly and rhythmically. Fibrillation or a fibrillating heart, like a bag of worms, so that heart is not pumping blood at all. Its not pumping blood out. Every time your heart pumps out of its chamber it will also supply blood to the heart muscles. A heart failure is caused by poor oxygenation because of poor blood flow to the heart muscles. If a part of your heart muscle is weak, its not gonna pump blood. Your hearts gonna have an ineffective pump so youre gonna have a heart attack. When you die, the manner of death is classified as natural. When you are stabbed, youll lose a lot of blood, thats the mechanism. Hanging, suicide, strangulation, the mechanism there is asphyxia, a lack of oxygen in the system. The medico legal report must show these three information. Unfortunately, our system of death, according to Doctor Fortun, is not scientific based and is haggled by the policy of no aggressive complainant, no case and the practice of relying mostly on witnesses. If theres no complaint, theres no case. Here is a case of a girl who died in a Monday morning. She was apparently well 4 days prior to her death. The following day she did not feel well, she complained of vague abdominal pain. She stayed in bed and ate what was fed to her. Two days before she died, she refused to eat and continued to complain of abdominal pain. Her mother noted that her abdomen was becoming distended. She still refused to eat the next day. And because of that the mothers live in boyfriend beat her with an electric wire. The child still didnt eat and died the following day. The mothers live in boyfriend was arrested and was charged with for violating RA 7610, the Anti-Child Abuse Law. The autopsy report concluded that the child died of pneumonia. As to the manner of death, there was no report. Based on the request of the mother this child was exhumed. This is the case where Doctor Fortun felt an abnormality in the childs rib. The child had bruises. The police were saying that she died of beating. Doctor Fortun found out that her intestines had telescope unto itself (the smaller part will enter into the bigger part) there will be intestinal obstruction. The cause of death is intussusception. The mechanism of death is the biological and physiological changes in the body; youre not eating, youre starving, youll have lactic acidosis and your heart is going to stop beating if its in an acidic medium. The manner of death is homicide because the mothers live in boyfriend refused to bring the child to the hospital even when the mother pleaded to bring the child to the hospital. But maybe its unintentional because he probably just did not know.
July 26 IDENTIFICATION OF THE LIVING AND THE DEAD Medical reasons for establishing the identity of a living person and a dead body: a person is comatose infant Page 14 of 37

person who has mental defect there is language barrier the person may tell false information regarding his identity even if details is known but personal details are needed to be confirmed for purposes of immigration or inheritance for paternity and filiations for proper support, inheritance and parental authority for investigation of the death especially if it involves mass disaster for purposes of inheritance, insurance, retirement, immigration, etc
You need the help of experts or forensic people like forensic pathologist, orthodontologist, anthropologist when the dead bodies are severely injured or severely mutilated, decomposed or skeletized. The identity of a person is established by comparing or matching the parameters that can be measured with the parameters of another person which is suspected to belong to the body being measured. The best feature on how to identify a person is his specific features that are matched to one that is known to a certain person. METHODS OF IDENTIFICATION: Morphological characteristics. This is a method of identifying criminals thru height, weight, general physique, hair color and length, presence of beard and mustache, skin pigmentation and other facial appearances, eye color, shape of the lips, and chin. These can differentiate one person from another (e.g. race). Picture: get the frontal and the side view shot (more often than not, your left profile is different from the right profile) To determine the age: white thing around the eye, teeth only up to age 25 and a range is given, x-ray (oxification centers, bone growth) Clothing and jewelry. Tattoos. Other marks: Striae, pimples, cleft lip, tribal marks, body piercing. Health records (scar, disease) Vertillian system of identification. Get 11 measurements from the person Write down and describe all the persons individual markings and personal characteristics It is flawed, it does not take into account changes with age Page 15 of 37

Was replaced with the use of fingerprints.
Fingerprints Three main patterns: loops, whirls and arches or a combination of any of these three. Used to ascertain a positive ID of a person No two persons have the same fingerprint even twins Cannot be altered by time or injury Can be extracted in any surface they come into contact with. Three Types Patent prints -left when a foreign substance on the skin of a finger comes in contact with the smooth surface of another object Plastic prints -left when a finger touches a soft malleable surface Latent prints impressions secreted in a surface or an object that is invisible to the eye, the result from perspiration from the sweat pores found on the ridges of sweat pores -invisible to the eye for -visible prints no need enhancements for needs enhancement (e.g. dusting)
-visible prints -no need enhancements
No less than 16 points of similarity before declaring prints to be identical The investigating agency must already have a file of fingerprints for comparison For decomposed or damaged bodies: use specialized technique from a fingerprint expert; can be obtained from despomated skin of the underlying epidermis after shedding the stratum corneum (the fisrt layer) when it comes to prolonged submersion; using the surface below the stratum corneum
Palm prints and sole prints it is believed that people do not have the same Page 16 of 37

Lip crease pattern Ear-shape Vein pattern in the dorsal part of the hands Bite mark Bones: sex, age only up to age 25, height, race, personal identiy: dependent on ante-mortem data Facial reconstruction: soft tissue thickness of the skull Photo superimposition: photo of possible individual is overlaid with a photographic transparency of the skull which has been scaled down to the eyes Tissue and cell samples: blood type, protein complexes, blood enzyme systems, etc DNA profiling: used in exclusion and identification thru body fluids, hair strands; DNA analysis can yield a positive identity
Principles o no two persons have the same DNA pattern except for identical twins or clones each part of your body contains the same DNA
If the DNA pattern left at the scene of the crime does not match the suspects DNA pattern, the suspect was never in that scene. If it matches the suspects DNA pattern, it puts the suspect in the vicinity of the scene of the crime but does not necessarily mean that he is guilty of the crime. The DNA molecule consists of two strands of sugar and phosphate molecules that link to one another to form a double helix. Ten percent of the molecule is used for genetic coding and the rest are silent. These silent zones repeat themselves, meaning, there is only 10 percent of the billions of molecules in the body and only a few percent is specific to you alone but the distribution is unique for each one of us, the sequencing is different. The DNA is found in the nucleus and it is a double helix. It is very stable but the specimen that contains the DNA that is to be analyzed can easily be contaminated by the collector. DNA typing is a well-established means of identifying human remains and is a powerful tool resorted to when traditional methods of identification are not helpful. Page 17 of 37

DNA fingerprinting is the last resort in identifying people. Its used for healthcare, pharmaceutical research, evolution and forensic. There are 3 ways of determining DNA sequences. Types of samples needed for DNA analysis: it must have nucleus (white blood cells, hair root, spermatozoa). Get a buckle smear from the side of your mouth, vaginal swabs and anal swabs to determine presence of semen or Y chromosome within 72 hours placed in a ref right away, blood. Semen on clothing can stay for a year. Half of our chromosomes come from our father and the other half from our mother.
Blood groups can only be used for exclusion in paternity or maternity testing; not accurate like that of DNA analysis. If the childs blood type is O and the mothers blood type is O, the fathers could be A or B. Samples for DNA testing: mother, child and probable father. In paternity exclusion, if theres none matching profiles in at least two DNA locations it can constitute conclusive proof that the alleged father is not the biological father. In child sexual abuse cases, it does not necessarily exonerate the suspect from the abuse charges; it just means that the abuse did not impregnate the child. In paternity inclusion, complete matches in the DNA profiles of the child and the alleged father will not necessarily establish paternity. The strength of the matches is determined statistically.
JULY 31 (SATURDAY)
IDENTIFICATION OF LIVING AND DEAD
Use of DNA evidence in courts: Important to use DNA- allowable for ID and testing of parentage SC said DNA can be used as corroborative evidence together with other evidences Find out how sample collected, handled, possibility of contaminating samples, standard procedure followed in analysis, proper standards followed in conducting tests and qualifications of the analysts who conducted the DNA tests (questions that should be answered when you present evidence in court) Page 18 of 37

By itself DNA cannot establish the guilt of an individual (powerful corroborative evidence) only DNA experts can say that the DNA samples belong to the suspect DNA experts are the most appropriate persons to answer questions regarding DNA forensic process. Find out his professional qualifications, how reliable is their DNA testing process and the laboratory itself. Expert witness will interpret the DNA results and will explain the match or exclude a suspect as a possible source of the DNA.
DNA report contains: what were the samples tested the controls used DNA profile of sample consistent with that of the suspects Statistics of the probability that the evidence sample came from the suspect Conclusion based on the results of their test
How are these interpreted? Independent DNA profiles of the victim (sexually assaulted kid) and the reference samples are compared. The results are either inconclusive or theres an exclusion or an inclusion.
1. Inconclusive - DNA testing did not produce info that would include or exclude the suspect. May result from improper collection, handling or storage and can occur when quantity of intact DNA is insufficient or sample contains complex mixture from several individuals (do not contaminate!) 2. Exclusion - if the DNA profile from the sample does not match the profile of the suspects DNA reference sample. Suspect excluded as a source of the DNA but does not equate to innocence and does not automatically absolve suspect of the crime because he may have committed the crime but did not leave any DNA samples. May indicate involvement of another person. 3. Inclusion DNA sample from the suspects DNA reference sample matches the DNA profile of the sample taken from the victim or scene of the crime. Suspect is included as a potential source of the DNA but does not automatically determine the suspects guilt. You have to present other evidences to prove if hes guilty or not. Statistical analysis will estimate significance of the match:
1. random match probability - probability that an innocent individual who is unrelated to the suspect and chosen randomly from the population will match the DNA profile taken from the crime scene 2. Likelihood ratio ratio of the probability that the DNA profile in the evidence sample came from the suspect and the probability that the DNA sample came from a random unrelated person. Ratio of the probability of the match given that the defendant is guilty to the probability of a match that the defendant is innocent. > 1, 000 = very strong evidence to prove that this DNA belongs to defendant Page 19 of 37

INJURIES - from blunt and sharp forces
Wounds/ injuries tissue damage from mechanical force or from non mechanical forces; breach in the skin; caused by outside objects or force either physical or chemical - Results from accident, act of self-harm (self-inflicted) or from action of a third party
How caused? 1. Kinetic caused by application of mechanical or physical force Mechanical force causes two types of trauma: blunt and sharp Blunt force trauma causes abrasions, contusions and lacerations Sharp force trauma leads to incised wound or stab wound
2. Non-kinetic injuries come from non-motion trauma like thermal, chemical, electrical, radiation or exposure to atmospheric pressure
Important when describing the wound how it looks like, what kind? Demand from doctor, you have to know whether blunt or sharp force, what are the dimensions, positions, etc.
Abrasion superficial type; involves epidermis; no bleeding involved; e.g. scratch; deep abrasions can have bleeding because of blood vessels Tangential glancing impact (something falls on your body) crushing; size and shape will depend on the kind of object which comes into contact with the skin Linear abrasion, broad, crushed.
Contusions, bruises (ecchymosis, hematoma) breakage or rupture of blood vessels cause escape of blood from blood vessels to the dermis resulting to discoloration External bruising and internal bruising (bruises on internal organs) The greater the force the greater the bruising the site of bruising does not necessarily reveal the site of trauma because blood is not static, can move by gravity initially reddish / purplish to yellowish or brown (d/t breakdown of hemoglobin) The usual guide in determining the age of the bruises has been discarded. It was discovered that some bruises will only appear later on when there Page 20 of 37

was already bruising in the muscles for a long time. depends on the site and how bad was the bleeding they do not accurately reflect the object causing them but there are some patterns that indicate the type of weapon used often associated with abrasions and lacerations less associated with incised/stab wounds because in stab wounds the blood is allowed to escape/ seep under the skin more prominent if force applied on bony areas so if you see bruise on abdomen greater force was applied for a bruise to result Can occur after death since blood vessels are easily broken when dead. Found on areas on the dependent part of the body (by gravity)
Lacerations result of blunt force overstretching the skin and there will be a split of the full thickness of the skin deep and will bleed important to look for bridging fibers (remain intact in lacerations and will not be cut) skin can be compressed within the applied force and the underlying bone rare in soft fleshy areas of the body margins are always ragged if caused by thin sharp object, the wound is sharply defined and may be mistaken for incision but under the microscope there could be abrasions and contusions on the edges and bridging fibers in the laceration
Sharp force injuries:
1. Incised wounds also caused by objects with sharp and cutting edge and distinguished from a stabbed wound by being longer than deep - Edges will give indication of the sharpness of the object used. Very sharp objects will not leave bruising on the edges, no bridging fibers. - rarely life threatening unless it cuts deep into a tissue like your jugular artery 2. Stab wounds wounds that are deeper than they are longer Depth of the injury will make it fatal because of the bleeding Any object with a point or a tip can cause it, edge need not be sharp. Pressed into the skin with enough force to overcome the natural elasticity of the skin Appearance does not necessarily mimic the cross-sectional shape of the object used. Contraction of the elastic fibers of the skin will distort a slit like wound after removing the weapon Shape of the wound can tell you if it was a single edged weapon or double edged knife Pushing the edges of the wound together is not an effective way of measuring the size of the wound and determining the size of the weapon Size of the wound will depend on the shape of the blade and how it was inserted. Movement of the knife in the wound will change the shape and can enlarge the wound opening If knife fully inserted bruising might result d/t the hilt of the weapon or by the hand of the assailant Page 21 of 37 -

Mechanism of Injury
3 ways of infliction of a wound
1. accident 2. self-infliction 3. action of a third party
By looking at the injuries alone it is very difficult to determine which of these three caused a wound. You have to look at circumstances. Get a history on how it was incurred.
Bite marks in a child is pathognomonic and the child was definitely abused. To identify the teeth marks you need a dentist and you need to get an impression of the suspects teeth and compare. It can also be a source for DNA collection.
DEFENSE WOUNDS Found in victims who are trying to defend themselves from an attack so it will depend on the kind of weapon used
Areas : Underside or posterior sides of the arms and hands
Self-inflicted injuries - no definite characteristics that define these. But a person who wants to hurt himself prefer stab or incised or gunshot wounds. In areas that can be reached, unusual areas include the eyes, lips, nipple and genitalia. Blunt force injuries are rarely self-inflicted.
Survival: If theres a lot of bleeding the body has a mechanism to prevent shock called Compensated shock. But if he will not get any medical attention and body cant maintain it, body will go to uncompensated shock and will lead to death.
Aug 2 Violence against women. RA 9262. When do violence against women and their children occur? Violence according to the WHO: the intentional use of physical force or power, threatened or actual against ones self or another person (here were talking about another person) that results in or has a highlight resulting in injury, death, psychological harm, mal-development or deprivation. The intentionality is always Page 22 of 37

associated with the committing of the act itself irrespective of the outcome of the violence. If somebody hurts another person or threatens to hurt another person that in itself, the intentionality is there already. There must be a relationship wherein one person perceives himself or herself as more powerful than the other person. So this would include threats, intimidation, neglect acts of omission or all types of physical, sexual and psychological abuse. Such an abuse could also happen within a marriage. It does not necessarily lead to injury, disability or death but it will pose substantial burden on individuals, families, communities, healthcare systems worldwide and this consequences can either be immediate, latent or can lasts for years after the initial abuse. The consequences such as psychological harm do not expect it to happen immediately all the time. RA 9262 is gender based. According to the UN Declaration on the elimination of violence against women, its a gender based violence performed by a husband or an intimate partner. In the US, most of the recorded incidents of injuries in women are from violence of their intimate partners. It occurs everywhere. It refers to any behavior within in an intimate relationship that causes physical, psychological, sexual harm, to those in the relationship. And the term battery issues the abuse occurs repeatedly in the same kind of relationship. Different forms: physical aggression, psychological abuse, economic abuse. Factors: the man grew up in an abusive atmosphere, witnessing domestic violence by children, couple married very young, the man is alcoholic abuse/substance abuse, economic stress, no support fort the family in the community, if culture accepts that men have the right to hit women. Two types of violence: the severe and escalating form of violence and the moderate form of violence. Traditionally, mans beating is a consequence the mans right to inflict physical punishment on his wife. There are many cultures that believe that a wife is a mans property. What are the events that trigger partner violence? Woman refuses to have sex. Not preparing the food. Woman asks where the money goes. A lot of men have no work. It is essentially about power and control. But women still stay in the relationship. Cycle of violence. First, tension building. Second, honeymoon stage. Back again to the tension building. Excuses of the batterers: I only pushed her; I did not hit her; Its her fault; Shes hysterical; she bruises easily Women in a violent relationship try to protect their children. They try to adopt in such a way that the children will be protected from harm. Witnessing domestic abuse by children is an abuse in itself. Consequences: they keep complaining of pain everywhere in their body even if there is nothing wrong with them, they may end up smoking, overeating, or they will stay idle, they become depressed Myths about domestic violence: it is not a common occurrence; women are just as violent as men; men are brought up to be the aggressive person; women are brought up to be the submissive group; alcohol abuse causes domestic violence (alcohol inhibits your actions so you are braver to hit the other person); domestic violence is usually a one-time domestic occurrence; men who batter are often good fathers. 40 to 70 percent of men who hit their wives abuse their own children either physically, sexually or psychologically. When there is violence in the family all members are participating in the dynamics, therefore, all must change to stop the Page 23 of 37

violence. Battered women are machuchisyic and provoke the abuse they must like it or they would leave. HITTING IS NOT DISCIPLINING. Battered woman syndrome. It refers to a scientifically defined pattern of psychological and behavioral symptoms found in women living in battery relationships as a result of cumulitative abuse. It is the psychological, emotional, behavioral reactions and deficits of victims and their inability to respond effectively to repeated physical and psychological violence. It is a state of a woman in a highly abusive relationship resorts to murder or aggravated result of her spouse as a result of her belief that it is the only way to save her from death. When a person is under chronic stress, there will be abnormal secretion of cortisol and because of that the brain becomes hyper-alert for danger and the woman now will be focused more on surviving to the point that she will forget about trying to maintain her healthy cognitive and social skills. Thinking properly becomes disrupted. Socially, she will not know to relate with her children and she may be even become abusive to her children, she will not know how to relate to her neighbors because all that shes trying to do is survive. Because of so much fear other parts of the brain will wear out. She may either create permanent memories of what has been happening to her and she may foresee that everything will just keep happening. There could also be extreme anxiety. Depression. Difficulty forming attachment to other people. In a way, she isolates herself. She can have sleep problems. She can be a very impulsive person. They will appear helpless. Exposure to a remand of earlier trauma to perceive threats or to generalize reminders will make either respond anxiously, shes gonna start to become panic, aggressive may even provoke threatening behaviors from others. There could be a post traumatic stress disorder. Any intrusive recollections of the traumatic events will create hyper-arousal or hyper-vigilance. Theres avoidance behavior, emotional longing, disrupted interpersonal relationship, body image distortion and sexual intimacy issues. When the cycle of violence becomes worse it may come to a point where she could kill the man when he is asleep or is drunk because that is the time that she is stronger, or she herself will end up dying. The medical evidences should include the interview of the woman as to what had happened. A social workers interview and investigation is also needed. What the doctor can add to that interview will the physical examination and documentation of the injuries, the laboratory examination, and psychological or psychiatric evaluation will also be good if the woman intends to file a case and other evidence that should include crime scene investigation, accounts from witnesses, and a social workers investigation also. Physical abuse. WHO: Child abuse or maltreatment that consists of all forms of physical, and/or emotional maltreatment, sexual abuse, neglect or negligent treatment of commercial or other exploitation resulting in the actual or potential harm to the childs health, survival, development or dignity in the context of the relationship of responsibility, trust and power. For medical evaluation we have to include the comprehensive medical history or child-sensitive forensic interview, physical and laboratory examination. We treat that patient and we do crisis interventions and referrals. The purpose of our evaluation is to evaluate the medical problems, gather evidences, and give the child a therapy by making sure that the child is safe and protected. In the US, it is the interviewer who tells the court what the child told her. The child-sensitive interview is done using the appropriate language depending on the childs age, non-leading questions are asked initially and when the child starts to disclose everything down to the specifics thats when we ask specific questions but make sure not to ask yes or no questions and make sure that the story comes from the childs mouth. Take into consideration the language development of the child. Children do not keep time. Children jump from one event to another. Page 24 of 37

Physical abuses are acts of commission by a caregiver. There has to be a relation of trust, power and authority. In RA 7610, although child abuse refers to infliction of physical injury, physical injury in RA 7610 includes but is not limited to lacerations, fractured bones, burns, internal injuries, severe injuries suffered by a child. It does not say who inflicts this injury, it doesnt say whether its intentionally inflicted kind of injury which WHO adds the word intentional. One. The injury is not only inflicted but its non-accidental. (The three mechanisms of injury: accidental, self-inflicted and action of a third party.) The pattern of injuries fit a biomechanical model of trauma that is considered. A lot of injuries have been scientifically studied and there have been conclusions are made wherein they said that it can only be caused by an abusive act of another person. The pattern of injuries may correspond to infliction with an instrument in a manner that would not occur through play or natural environmental interactions. Shaken baby syndrome. When the baby is shaken he will have subdural hematoma, thats bleeding within the brain, retinal hemorrhages, without any evidence of external injuries. The babys head is bigger than that of the body. The neck muscles are weak. The baby can present sudden seizures, stop breathing, vomiting, and poor feeding. Another injury that can happen is rib fractures. Chest compression in CPR does not cause this kind of fractures. Another problem that can happen is cervical cord injury wherein the baby stops to breathe. When you shake the babys head, it will cut the nerve connections in the brainstem (it is where your respiratory and circulatory centers are, it is what you call the cervical cord), it is known as diffused axional injury, no time for bleeding to happen. Retinal hemorrhage is a bleeding at the back of the eye. From a lot of short falls (short falls-falls less than 4 feet), majority of children do not have serious head injuries because the extremities hit the ground first. Medical evidences will be the medical history, family and social history, investigation of the childs environment, physical and laboratory examination. Questions that you have to ask: When did it happen? Where did the injury occur? Who witnessed at the time of possible injury? What did the caregiver do after the injury? In formulating our impression we have to ask these questions. Does the history reasonably explain the injury? Was there any explanation given as to how the child incurred the injuries? Is the statement given consistent with the development capabilities of the child? Is there any delay in seeking medical care? Is the history vague? Medico legal principles: we can only offer an opinion of the presence of an abuse because we want to put the child in a safe place after. We cannot give you an opinion about the guilt of an alleged perpetrator nor can we give you an opinion of his intents. August 9 INJURIES FROM FIREARMS Firearm - weapon that fires single or multiple projectiles propelled at high velocity by gases produced through rapid confined burning of a propellant. Projectile any object that is sent through space by the application of force. For firearms, the projectile is called a bullet or a pellet or a shot which is made of metal (usually lead). Some projectiles will fragment inside the target while others do not. Two basic types of firearms: 1. Artillery (usually the big ones) Page 25 of 37

2. Firearms - very portable and has a range of accuracy of less than one mile. a. riffled weapon which is a pistol and a riffle b. shot gun Handgun or pistol the smallest of all firearms, fired from the hand, it has a riffled barrel. You can have a revolver wherein after the bullet is fired a brass case which contains the explosive remains in the cylinder unlike an automatic when it is fired the empty cartridge case falls on the ground. Riffle - its a long barrel, with a high muzzle velocity, a riffled barrel, and built for accuracy and long range (1.6 km) and you have to aim to hit your target Shotgun firearm with a smooth bored barrel designed to fire multiple pellets that will come out from the barrel and to be fired from the shoulder. It is designed to quickly hit a moving target. You dont need to aim, just point and shoot The other types are machine guns and submachine guns. Ammunition or projectile its called a round or a cartridge. The cartridge packages the bullet, the gun powder into a single metallic case precisely made to fit the firing chamber of a firearm. The cartridge case expands and seals the chamber against rearward escape of gases. The primer explodes on compression igniting the propellant. There are two types of primer: the center fire and the ring fire. The propellant is within the cartridge. This propellant burns to produce large volumes of gases under pressure. The tip is the bullet (either lead or metal jacketed), which is the part of the cartridge that leaves the muzzle. Projectile from a shotgun - shotgun shell. Cylindrical cartridge of a plastic or cardboard tube with a brass base. Contains tiny lead shots. Bottom of the cylinder is the explosive powder and the center is your detonator. Leaves the barrel as a composite missile becoming approximately 300 individual shots as the missile moves further down the barrel. Trigger is squeezed, the firing pin will strike primer and ignite the powder within the cartridge and the burning powder will create the pressure which will push the bullet out of the muzzle. Important to know these things to identify whether the bullet wound is from close contact or distant contact. If close contact you will not only see the bullet wound but also some of the gasses, gunpowder residue on the victims body as compared to distant contact, bullet entry is the only thing evident. Wound ballistics study of projectile penetration. Wounding effect of a projectile is actually produced by the transfer of kinetic energy from the projectile to the tissues. The greater the kinetic energy or the velocity the greater the wounding potential. If projectile does not exit the body then the energy in that projectile will be projected within the body causing further damage. If it exits the body then only some of the kinetic energy is transferred to the tissues. Mechanisms by which projectile disrupts tissue: direct laceration of the tissue drilling effect, it just goes through the tissues. Main mechanism in a low velocity weapon. Permanent cavity is produced. On the other hand a temporary cavity is produced by the shockwave or the other pressures that come along with the firing of the gun. Can be produced surrounding the permanent cavity where the bullet passes by. But if it exceeds the natural elasticity of the tissue, that tissue can rupture and it becomes a permanent cavity. In a description of a GSW (gunshot wound) it is important that the doctor will describe the wound and its location to determine circumstances of the shooting. Permanent cavity - where the projectile passed through the skin Page 26 of 37

Abraded margin around the wound- like an abrasion or contusion ring or bruise; cause is the forward motion of the bullet upon entering the skin abrading the margin of the entry wound Microtears- tiny lacerations on the edge of the wound from high velocity center fire rifle bullet Graying lubricant or debris of the bullet wiped off the wound edge, smudging or blackening deposition of soot from partially burned gasses. Tattooing (Stippling) burning grains imbedding the skin; if it is seen it means immediate or close range distance Branding or burning from the hot gasses of the muzzle at close range Muzzle contusion caused by the skin impact against muzzle (close range) (e.g. muzzle imprint) Contact range wounds muzzle to target distance: in contact with the body or only a few centimeters away from the body. Edges of GSW seared by the gasses, blackened by soot and propellant, and there is concentric blackened zone. Metal fragments may be found within the wound. Gun placed over bony areas, GSW can come out in a stellate (x-shape) or lacerated appearance. Muzzle to target distance is greater than 10 feet all you will see is the GSW entry. Exit wounds (in rifle wounds) will have inverted flaps because the bullet will go out. Bigger than an entrance wound. You may not see any stippling or soot. SHOTGUN WOUNDS - large contact entrance hole with significant damage to the margins + gun residue deposits Close range (less than 5 ft from muzzle to target) can produce single large defect which will approximate the weapon bore. Intermediate range (5 to 10 ft) central defect produced by the shot and the wadding with surrounding wounds because of the tiny pellets. Once ammunition leaves muzzle, pellets will start to separate. Not only central defect can be seen but also tiny defects coming from individual pellets. Long range whole thing breaks out. You still see tiny concentric defects from individual pellets. Exit wounds rarely seen if fired in the chest and abdomen. Can be seen if fired in the head, mouth of huge rugged appearance. How are they supposed to be investigated? Body must be handled as little as possible to avoid loss of evidence Hands must be paperbagged (not plastic) because in plastic moisture can develop. Body transported in a body bag to preserve trace evidence and avoid contamination During autopsy, MD must take an x-ray and look for metal fragments in the body. Medical Examiner plus expert must recover residues with 10% nitric acid and swab the area, not a paraffin test. Paraffin test is obsolete. They must describe the wounds in detail Ff. questions must be answered: 1. is there projectile present? Where? Page 27 of 37

2. projectile fragments present? Where? 3. type of weapon or ammunition? 4. path of projectile? Firearms investigation is a comparative investigation. Done macroscopically and microscopically. Bullets are compared and matched to specific firearms. As well as, accurately determine the distance of the shooting. Bullets will have rifling of the FA that was used. Rifled FA will leave a mark on bullets. Each FA has a unique rifling pattern. If no marks on the bullet then gun used has smooth barrel without any rifling. ACCIDENT, SUICIDE OR MURDER? Suicide no notes are left in majority of cases. Wound site within the range of the deceased. Usually contact wounds. Sites of the wound usually include the head, chest and abdomen. Unusual location, think homicide. Weapon should be present at the scene of the crime. May not be near the victim since he may have moved if he did not die instantly. If suicide ruled out it could either be accident or homicide so look at the circumstances. Multiple FA wounds suggest homicide. Sept 6 INJURIES FROM EXPLOSIVES Explosive. A mixture of an oxidizing agent and fuel. Two parts: 1. Low explosives exert a throwing effect in a factory or people nearby of any object 2. High explosives they can explode between 1 thousand to 8, 500 meters per second causing more shattering and devastating effects in a farther distance Explosion. A result of endothermic chemical reaction wherein there is a generation of huge amount of gas with the release of vast amount of heat that occurs very quickly. Different types of bombs: 1. General purpose 2. Fragmentation 3. Penetration bombs 4. Cluster bombs Mechanisms: Blast caused by tremendous dynamic over pressures generated by recoillation of a high explosives. Half of the total energy generated will cause the bomb casing to swell 1.5 times its normal size before it will erupt into small fragments and that energy will send the fragments flying out in all directions. The remaining energy is expended in the compression of air surrounding the bomb producing the blast effect. Destroys the skin or muscle even to the point of amputation. Damaging effects: fragmentation, crater-ring effect, fire, pure blast (caused by gas) Secondary effects: burns, missile injuries, pepper, all types of injuries from collapse of a building and destruction of a vehicle Exchange principle: When any two objects come into contact there is always Page 28 of 37

transference of material from each object onto the other. Paraffin test. A test that determines the presence of nitrates and nitrites that may have come from a gun powder or primer inside the bullet casing that ignites when a gun is fired. It has to be warm to open the pores of the skin (because the gun powder is embedded into the skin) so that the nitrate compounds will go out and will be left in the paraffin wax. Presence of nitrite or nitrate in the wax glove (with the use of an acid) produces specks of violet-blue colors.
ASPHYXIA. Absence of pulse. It describes a range of conditions for which the lack of oxygen is considered the cause. Mechanism: obstructive or non-obstructive The obstructive type is medico-legally significant. Classical Features: It is not diagnostic. Not definite signs of asphyxia like: facial congestion, facial edema, facial cyanosis, petechial hemorrhages in the skin and in the eye, star dose spots Conditions/causes 1. Suffocation Lack of oxygen in the inspired air Example: Putting plastic bags on the head of prisoners There is quick death and minimal signs of asphyxia except for pallor in the face Not struggling to breath; there is low external pressure 2. Smothering The victim struggles May experience cyanosis and congestion Bruises and abrasions on the face, on the lips, or inside the mouth Non-struggling victims: may not see any of the signs; difficult to diagnose 3. Choking or gagging Internal obstruction of the upper airway passages by an object or substance impacted in the pharynx or larynx Mucus membranes swell or congest if you breathe thru your nose There will be respiratory distress, can become cyanosis and congested face and neck up 4. Strangulation or hanging Three forms of prime forensic importance Manual strangulation Ligature strangulation use of band around the circumference of the neck Hanging pressure of the ligature on the neck produced by the weight of the body Can result into two effects: classical asphyxia signs the person died a slow death; no asphyxia signs there was sudden cardiac arrest The effects and events depends on the method used, size of the pressure, Page 29 of 37

and the force with which the pressure is applied Jugular veins drain venous blood (un-oxygenated blood) from the head. If there is obstruction, the blood will remain in the head. The person will swell, congest or become cyanotic. The arterial veins will rupture causing petechial hemorrhages underneath the skin. Obstruction in the carotid artery (carries oxygenated blood) causes cerebral skemia and the person will collapse because of lack of oxygen in the brain. Stimulation of the barrow nerve endings in the neck will bring about the slowing of the heart. External signs: abrasions and bruises in the neck area, laryngeal damage, 5. Traumatic asphyxia (restricting the movement of the chest) External pressure is put on the chest thereby restricting respiration Classic signs: very congested from face and neck up, person becomes very blue or red, extensive petechia Blood from above the chest cannot return to the heart, its just like obstructing the jugular veins 6. Postrial asphyxia Disabled or unconscious person lies with the upper half of the body lower than the rest of the body There is pressure in the abdomen that does not allow the diaphragm to move; its like traumatic asphyxia where there is restriction of chest movement Commonly seen on persons arrested, they are pushed to the ground Hemoglobin carries oxygen but it prefers carbon monoxide. Failure of oxygen utilization will paralyze the chest muscle. HYPOXIA. Partial lack of oxygen. ANOXIA. Complete lack of oxygen. Sept 13
TRANSPORT INJURIES, DROWNING, ALCOHOL
3 GROUPS OF VICTIMS Pedestrian, passengers, cyclists or motorcyclists
TRANSPORT INJURIES:
Primary injuries from the direct contact of the vehicle Primary injuries are recognizable and may take the pattern of the bumper Page 30 of 37

for e.g.. Wherever the injury is thats the point where the pedestrian was hit. Clues as to the speed on the car: < 20 km/hr thrown off the hood either forward or sideways 20-60 km/hr victim may fall on the hood and head may strike windshield 60-100 km/hr victim may fly up in the air and he can fall on the car or beyond the car.
Secondary injuries from the contact of other objects or the ground after contact with the vehicle Often more serious and potentially lethal than primary injuries (e.g. head and spinal injuries)
Car occupant The injuries suffered will depend on the kind of impact Vehicle hit from behind called acceleration impact Side impact and rollovers least common From the front - there will be acceleration then deceleration. Deceleration impacts without restraint (no seatbelts) and youre accelerating with the car and the car hits another car your body is still accelerating; your head can hit the windshield or your chest the dashboard and other injuries on the upper part of the body. There could also be injuries on the lower part of the body, in the ankles, hips or knees. Organs in your body also accelerate and in the act of deceleration pulmonary veins, aortic veins attached to the body can be torn off so theres internal bleeding. You may also sustain injuries within your brain since the brain moves in your skull. you may have concussions and contusions.
Motorcyle injuries due to falls from the machine you can have abrasions, injuries in the head bicycles more milder forms since lower speeds but the problem is when they are hit by other vehicles wear appropriate safety gears
IMMERSION AND DROWNING Different things
Bodies recovered from water could have died from natural causes before entering the water. Determine WON victim died of natural causes before entering the water or while in the water having entered it either voluntarily or accidentally. Did he die of unnatural causes before entering the water? Did he die from exposure or hypothermia while in the water? Died of injuries after entering water? Did he die of submersion or drowning?
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Submersion just actually being in the water. A person who drowns can have signs of being submerged but a person who was submerged in water does not necessarily mean he drowned. If you died before you were placed in the water you are submerged.
S/Sx of Submersion: 1. 2. 3. 4. washerwomans fingers/hand macerations and skin will peel off after weeks of immersion decomposition Eventually your body will float. The only time body wont float is when youre submerged in very cold water.
How do we know if these injuries are post-mortem or ante-mortem? Injuries must be seen under the microscope and if theres inflammatory reaction seen then you know injuries are before death since there are no inflammatory reactions if you got injured after you died.
DROWNING you die of suffocation because of water within your lungs and you have to be immersed in water Effect depends whether you drowned in fresh or sea water. Fresh water is absorbed into our circulatory system resulting to volume overload and hemodilution, eventually leading to cardiac arrest. Sea water more concentrated than blood, so fluid in our blood will go out into our lungs and theres pulmonary edema or congestion resulting to hypoxia, respiratory arrest, cardiac failure and cardiac arrest Post mortem findings variable and cause of death hard to prove 5 stages a. You struggle, you may find bruises in your chest and shoulders b. You get tired and you sink c. You dont want to breathe in water so you stop breathing. Because we hold our breath carbon dioxide goes up so respiratory centers in our body say breathe so we breathe in water d. Cough vomit, loss of consciousness. Convulsions. Involuntary respiratory movements and we keep inhaling water. e. Respiratory arrest and cardiac arrest. You could drown within 10 minutes In 10-20% of the victims laryngospasm can happen and since larynx remains closed water cannot enter lungs = dry drowning The rest theres relaxation of the airway and water enters the lungs There can be blood tinged froth in the mouth and nostrils which is more common in seawater drowning. Sand, silt, seaweed may be found in the lungs sign of life before immersion BUT Finding of foreign material in stomach weighs heavier than finding them in the lungs because theres a sphincter of some sort in the stomach which does not relax when youre dead unlike airways which can relax so water may flow freely.
Mechanism of death as a Result of Submersion is not always classical drowning because most of them die quickly and the result is usually cardiac arrest. Page 32 of 37

No universally accepted laboratory test to confirm drowning. If they find diatoms in the blood or lungs its just corroborative evidence of drowning. Forensic pathology - if theres water in the lungs victim was alive when he entered the water and if theres no water in the lungs it can be dry drowning or death prior to submersion. Pathologist must determine if theres laryngospasm.
Questions to answer in an investigation: 1. 2. 3. 4. was the person dead or alive when he entered the water is the cause of death drowning? If not what is the cause of death? why did the victim enter the water? why was the victim unable to survive in the water? Did this victim have other health problems or he was already injured? 5. what were the circumstances preceding death? very important to identify the body. 6. what were the circumstances when the body was recovered? 7. autopsy findings #s 1 and 2 are very important because these will have to be correlated with autopsy findings and if theres concurrence between the two then pathologist can make the findings.
ALCOHOL Alcohol abuse usually encountered in child abuse and rape cases. Its a drug and addictive. Makes one prone to accidents and an underlying cause of misdemeanor, assault and homicide.
S/Sx of alcohol intoxication: 1. Excitement - lack of inhibition or self-control, feelings of well-being 2. Incoordination and Confusion loss of nervous control of your body, blunting of perceptions, no muscular corrdination, nausea, vomiting, cardiac and respiratory symptoms 3. Narcossis or Coma deep sleep, slow breathing, paralysis of cardiac and respiratory centers which can lead to death Males cannot say that they could not have raped a girl because they were drunk because erection can happen in the excitement stage. On the other hand, they take advantage of girls when the girls get into the incoordination and confusion stage (Drug facilitated sexual abuse)
How do we diagnose drunkenness? 1. 2. 3. 4. 5. 6. 7. alcoholic smell of breath or vomitus dry tongue excessive salivation irregular behavior bloodshot eyes thickness of speech tremors, error of coordination and orientation Page 33 of 37

8. Best tests: blood alcohol content (BAC), urine test for alcohol and breath analyzer test Tests for error of coordination: 1. Romberg test 2. eye movements - place a pen in front of his eyes and theres nystagmus and place the object on the side of the eyes and theres jerky movements 3. walk and turn test walk in a straight line heel to toe 9 steps then do a quick turn 4. One leg stand 5. finger to nose test 6. let him pick a small object from the floor without falling off 7. may also be asked to do some tasks like recite the alphabet in a rapid fashion BAC Normal below 0.5% (? Maybe Maam meant 0.05), .1-.15 % - impaired faculties, not fit to drive vehicles, if = 0.15% and non-habitual drinkers intoxicated to the point of staggering, 0.2% habitual drinkers at the second stage and 0.5% stage of Coma.
Factors that affect absorption of alcohol: 1. weight- the heavier you are, the more water content and since alcohol is soluble in water, alcohol is easily absorbed in the water content of our body so a person with more water content does not easily get drunk as a person with less water content or weight 2. Fatty foods delay alcohol absorption. Alcohol is absorbed in the small intestine but you can delay absorption if alcohol stays in stomach. Sept. 20 Understanding the Child Child development: - Continuous process that starts from birth to maturity, and goes to define stages and phases. Before you can go to the next phase, the child must master first the previous stage. - Now the skills and the complexities as he grows older centers all in the physical, mental, social, and emotional function of that person. It affects cognitive development, emotional development, and social development. I. First 3 to 4 years of baby: - Neurons start to connect with one another. And the only way these neurons get connected with one another is if the baby is stimulated at the time when he is born. - Experience leads to neural changes in the brain. - Visual stimulation should happen in the first 6 months for the necessary neural pathway to develop. - You are now developing communication with the baby. If you meet the needs of the child, that child will learn to trust you and will develop an attachment to you as a caregiver. - If you need the baby to master a certain task, he must be stimulated at the right time, given the right experience. Example, a 6-month-old baby, you cant teach that baby to walk, since he has not developed the muscles to Page 34 of 37

support his own body to walk or stand on his own or balance himself. They learn to recognize their father and mother. When looking at objects and you hide it right away, they will think the object is no longer existing. They dont know the object is there and eventually as they grow older, peek-a-boo is an important game for babies, because they will learn you are still there actually. Touching is very important for children. For children who are not touched at all, when they grow up they dont want to be touched, since its strange for them to be touched. These babies are learning to be autonomous, they are learning how to toilet train and how to be independent and if you dont allow them to toilet train themselves, learn new skills, they will not develop self-esteem. They now have the ability to symbolize. In the beginning, they know the mental image of what an apple is. By the time they are 1 or 3 years old, now they can say this is an apple. So they are ready to play with other people. They will only do things for the approval of a parent, they will do things not to be punished. Thats all what they care about for the first 3 years of life. The sexual behavior at this stage is more on touching and looking. These are just learning. Sexual behavior at this age is merely knowing about the difference between the vagina and penis. As early as two years of age, they already learn the concept of right and wrong. It has nothing to do about pleasing the parents or they are being punished. Moral control is internalized by age 6 through consistent parental monitoring, praising of good behavior, identification of parental values, etc.
Impact of abuse at this stage: - For babies, as they grow, anything the parents do is correct, so if the babies sees the father and mother quarreling, they would see that as a normal thing to happen. - When they are abused at this age, especially when it comes to corporal punishment, they will only understand the pain; they dont understand the reason for the punishment. - These children are egocentric in thinking. Everything is I, me mine. They cannot relate themselves to the outside world. Its up to the parents to teach the child to relate with the outside world by allowing the child to play, to converse and talk with him, to interact with his environment, to do things on his own. - Children have immature reasoning. They think everything that happens is their fault. If they get physically abused, the child thinks, Its my fault. - In court, lawyers should argue objections out of the childs hearing. The child will think its his fault: My lawyer is shouting at me because I probably did something wrong. II. Preschool: - May signal the start of mental and behavioral problems. The child grows older, learns new skills, learns to be industrial, etc. If the child doesnt learn new things, she will learn not to take any initiative at all and not develop selfesteem. - Morally, they will do things to please the other people other than the parents. Now they have a conscience and are aware of social norms. - A 4-year-old victim will say, Hindi ako magsasabi kahit kanino kasi yan ang sabi nila. Or Hindi naman ito bad kasi ginawa ni tatay. Hindi naman masakit, nakakakiliti nga. - A 9-year-old victim will say, Bastos tong ginagawa ko. Kung magsumbong ako, kawawa naman si tatay, baka makulong din siya. A 4-year-old is more inward-looking as compared with a 9-year-old. Page 35 of 37

Impact of abuse at this stage: - Research shows that those with multiple personalities disorders and other forms of disassociation suffered abuse prior to 8 or 9 years old. III. Adolescence - The offset of adolescence for girls is at 10-14, boys 13-14. Theyre now learning how to think abstractly, but their thinking is still egocentric. They cannot handle hypothetical situations yet. - They now follow rules and the values of society, but they may not understand the concept of values and rules. But here, theyre finally learning who they are. - Initially, it was thought that the brain develops only in the first 4 years of life, when all the neural connections are being made. It was found that during the adolescent stage, a lot of the neuron pathways that were hardly used got pruned away and new pathways are being created. Another thing that they learned was that the development of the brain is from the least complex to the most complex, which is up in front. - The frontal lobe, where you have what is called the neo-cortex, develops, the area that regulates our emotions, abstract thinking, and helps us do our executive functioning. In teenagers, this is the area thats most developed. The frontal cortex reaches full maturity around 20 years old. Its the area for planning, reasoning, impulse control, regulation of emotions, learning from experiences, and weighing risks and rewards. This is the last part of the brain that develops. Some studies have shown that this is completed at the age of 25 for males, earlier in females. - The child has preference for physical activity. - The person has difficulty holding back or controlling emotions. Theres still no adequate control from the pre-frontal cortex to the amygdala. (Mood swings! Try to remember your teenage years.) - Studies show that, although the intellectual activity develops at 16 to 17, psycho-socially, hes still not mature until hes 25. - The adolescent brain is a reward-seeking brain, this is where theyre susceptible to pear-pressure. At the age of 14, they tend to commit crimes. - So the adolescent is actually still egocentric. They believe that they alone have difficulties, no one else can understand or sympathize. They believe that nothing can harm them. Morality: - Ability to differentiate between right and wrong and understand how to make choices. This is discernment. Again, the childs physical, intellectual, emotional, and mental skills, as well as his environment will influence the development of his morality. So you have to look into his background. IV. 16 20 years old (Young adulthood) - They continue to develop, emotionally, physically, and morally. Now they get into relationships. When it comes to sex, its more on experimentation in the early stages. But as they go into 17-19thats what you call late adolescence its already more for being in a relationship. This is part of normal development. Its up to you to guide your children. - Distinguish between occasional experimentation and enduring patterns of troublesome behaviors. These are usually harmless experimentation. Seemingly behavioral problems are not enduring problems. We have to distinguish those problems that arise during adolescence and those that have roots in earlier periods. Most teens who have recurrent problems with the law have problems at home and at school from an early age. (Hello, Joavan Fernandez! The newspapers keep saying, the adopted son2x. Theyre just rubbing it in. He might not have developed attachment as a child.) When does attachment develop? Before age 1. Page 36 of 37

Many of the problems adolescence experience are transitory in nature and are resolved at the beginning of adulthood. The effects of being abused are: It can affect their identity, their intimate relationships. In young adulthood, you learn whom you care to be with. In adulthood, you learn what you care to do and who you care to be, what and whom you take care of.
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NO formal training on how one becomes a Medico-legal officer. Page 1 of 37