The Autopsy Report

In preparing an autopsy report in a death caused by gunshot wounds, it is always best to group the description of wounds in one area labeled "Evidence of Injury," rather than scattering this information throughout the protocol. Thus, when a bullet entering the left chest perforates the left lung, the heart, the right lung, and exits the back, one should have all this information in one area of the autopsy report rather than scattering it among the External Examination and the description of the individual internal organs. Once the description of the injury to the organ has been made in this section, there is no need to redescribe the injury in the area of the report devoted to the organs.

Each entrance wound should be given an arbitrary number for reference purposes. A wound should be fully described as to location, appearance, path of the missile, injuries produced and site of lodgement or exit before description of the next bullet wound is given. There is no necessity to assign a number to an exit. This latter practice is often very confusing to the subsequent readers of the autopsy report.

The first information to be noted in the autopsy report is the location of the entrance wound. The wound should be located in terms of its general geographic area, e.g., the left upper chest, followed by its distance from either the top of the head or the soles of the feet; the distance from the right or left of the midline; and most importantly its relationship and distance from a local landmark such as the nipple.

Measurements as to location may be in either the English or the metric system. Since most lay people in the U.S. do not understand the metric system, and the majority of people who will see a forensic autopsy report are lay people, the English system is preferable. Describing a gunshot wound in relation to a local landmark is usually of greater value than locating the wound from the top of the head or so many centimeters or inches to the right or left of the midline. It is easier to visualize the location of a gunshot wound of the left chest as being "one inch above the level of the nipples" and

"one inch medial to a vertical plane through the left nipple," rather than "20 inches below the top of the head" and "three inches to the left of the midline." The value in using local landmarks becomes obvious if one considers the location of a wound 20 inches below the head in a six foot 11 in. basketball player compared to a five foot secretary. This does not, however, remove one's responsibility for locating the entrance from the top of the head and to the right or left of the midline.

After the entrance wound is located, the size, shape, and characteristics of this wound should be given. In contradiction to the suggestion that measurements locating the wounds on the outside of the body should be in the English system, measurements of the wound itself should be in the metric system for greater accuracy. Use of the English system of measurement, with its confusing mixture of sixteenths, eighths, and tenths of an inch, often results in errors or misconceptions as to the size and configuration of a wound. While the use of the metric system may be confusing to the lay public, the value of its simplicity and accuracy outweighs this consideration in this situation. The presence or absence of an abrasion ring, its symmetry, and its width should be described. The presence or absence of soot and powder should be noted in all cases. When soot is present, the configuration of the deposit along with its size and density should be described. Searing of the edges of the wound or adjacent skin should be noted and described in detail. When powder tattoo patterns are present, the maximum dimensions of the pattern and its density should be described. In measuring the pattern, occasional stray tattoo marks from the main powder tattoo pattern should be ignored. Unburned or partially burned grains of powder may be recovered. If so, an attempt should be made to identify them as flake, ball, or cylindrical powder. Grains should be retained for identification by a firearms examiner if the prosecutor is unsure of the type of powder present or wishes independent confirmation. The relationship of the bullet entrance hole to the distribution of the tattooing around it should be described.

Description of the abrasion ring or zone of searing around the entrance can be done by relating the appearance of these wound characteristics to the face of a clock whose center is the center of the bullet hole. Thus an eccentric abrasion ring may be said to average one (1)-mm wide, except from the 3 to 6 o'clock positions, where it averages three (3)-mm wide.

In contact wounds, if a muzzle imprint is present, the imprint should be described fully. If the weapon that is alleged to have produced the wound is available, comparison should be made of the muzzle end of the weapon with the imprint. It must be realized that the size of the imprint on the skin may be twice the actual dimensions of the muzzle.

After the external appearance of the wound is described, the path of the missile through the body should be given. The organs injured and the amount of blood present in the body cavities should be noted. The point where the bullet either lodges or exits the body should be described. It is helpful to describe the point of lodgement or the point of exit in relation to the wound of entrance, e.g., "three (3) in. below the level of the wound of entrance, one (1) in. to the left of the posterior midline." This description often aids one in visualizing the trajectory of the bullet through the body. A brief sentence about the overall direction of the bullet as it passes through the body is often helpful to an individual who has to read the autopsy protocol. Thus, the bullet may be said to have traveled from "front to back, downward and from right to left." The prosector should try to avoid terms, such as "medial," "dorsal," "ventral," "superior," or "inferior" in describing the bullet trajectory, since most lay people are unfamiliar with this terminology and forensic autopsies are more often read by lay persons than by physicians.

Exact calculation of the angle that the bullet traveled through the body is not possible and is often misleading. At the time of autopsy, the body is in an unnatural position, e.g., flat on its back and not upright. Calculations of the angle fail to take into account movement of the thorax, diaphragm, and internal viscera during the normal processes of breathing; distention of viscera by fluid, air, or food; the effects of gravity on the position of the internal viscera; and bending and twisting of the body at the time of bullet impact.

When a bullet is recovered from a body, removal should be done with the fingers, not with an instrument. Using instruments to recover a bullet can result in scratching of the surface and interference with ballistic comparison. If a bullet is recovered, it should be described briefly in the autopsy protocol. The general appearance of the bullet, i.e., deformed, un-deformed, lead, jacketed, or partial metal-jacketed; and the approximate caliber (if known) should be stated. The prosector should then mark the bullet with initials or numbers so that they can identify it later. This marking should never be inscribed on the side of the bullet, as it would obliterate rifling marks. Any inscription should be put on either the tip or the base of the bullet. After the bullet is inscribed, it should be placed in an envelope. The envelope should be labeled, at a minimum, with the name of the deceased, the autopsy number, the date of autopsy, what was recovered, where it was recovered, and the inscription put on the bullet. The prosector should then sign their name under this information. The envelope should be kept in a secure place. At the appropriate time, it should be turned over to a representative of the Criminal Investigation Laboratory or the police. At this time, a receipt for the bullet should be obtained as proof of maintenance of the chain of evidence. Occasionally, a cartridge case will be recovered from the clothing of the deceased; in such a case, the casing should be retained. It may be marked with a number or initials with these marks placed either in the mouth or near the mouth of the casing.

In the case of shotgun wounds, the size of the shotgun pellet pattern or the entrance hole (if the pellets have not "opened up") should be described in the autopsy report. With shotgun pellet patterns of the skin, just as in tattooing, one should ignore stray pellets and measure only the primary pattern. A representative number of pellets and all wadding (if any) should be recovered.

After the first gunshot wound is described, the process should then be repeated for any other gunshot wounds. Each description should be complete in itself from entrance to either recovery of the bullet or exit. There is no need to re-describe the injuries in areas of the report devoted to the individual organs.

After the description of the gunshot wounds, there should be a description of the clothing in regard to defects produced by entering and exiting bullets. These defects should be located at least in a general way. It should be noted whether powder or soot is present around these defects. Examination of the clothing with a dissecting microscope is strongly recommended. One should note whether the defects correspond to the wounds. The clothing should be air-dried, packaged in paper (not plastic), and either released to the police agency or sent on to the crime lab for further examination.

Appendix B may be consulted for a more general approach to the forensic autopsy as well as how it may be presented.

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