Misdiagnosed Injuries of Unusual Gunshot Wounds in the Clinical Forensic Practice

Introduction

Gunshot wounds are common in the forensic practice. Large percentage of the mortality rate is caused by gunshot wounds [1, 2, 3, 4]. The specific features of gunshot wounds make it easy to determine the entrance and exit wound whereas the typical entrance wound occurs when the bullet is traveling on a straight course with negligible yaw and strikes perpendicularly against the body surface. In this scenario, one would expect a punched out, circular defect surrounded by a thin abrasion rim. Variations of the wound appearance can occur due to bullet entry angle and the body surface struck making eccentric or even irregular abrasions surrounding the defect not uncommon [5, 6]. In some cases in the clinical practice gunshot wounds can be misdiagnosed by the clinicians, especially when atypical ammunition has been used or in cases of long range shots, ricochet bullets and shots trough solid material [5, 6, 7]. An atypical entrance wound or even multiple entrance wounds are primarily the result of an unstable, non-axial flight of a bullet or of missile deformation [6], but may also be caused by the use of atypical ammunition and weapons such as homemade firearms [5]. The disadvantages in using cartridges of a smaller caliber than those designed for the gun include: lack of accuracy, low velocity, barrel fouling, damage to the chamber, or leakage of hot gases from the barrel and chamber because these cartridges do not occlude the barrel [8, 9].

Discussion

Forensic expertise, especially autopsy, is of crucial importance to the determination of the cause, manner and circumstances of death. Therefore, it represents the golden standard in the evaluation of violent or unclear cases of death in line with Recommendation no. R (99) 3 of the Committee of Ministers to member states on the harmonization of medico-legal autopsy rules [10, 11]. The investigation of gunshot deaths often presents a challenge to the forensic pathologist. All available data from the death scene investigation, radiological and laboratory analyses and, in particular, autopsy findings have to be considered in order to reconstruct the events prior to the death and to accurately determine the manner of death.

The forensic pathologist needs in-depth knowledge and vast practical experience to handle cases that appear to go beyond the ordinary [12]. On the other hand, doctors in clinical practice can sometimes misdiagnose gunshot wounds especially if wounds lack the usual and expected features, such as the shape and appearance of the entrance wound, the trajectory of the projectile or the clinical findings. Misdiagnosis can result from multiple reasons such as misinformation, superficial approach, lack of experience, inappropriate local examination, lack of additional examinations, mistreatment, poor communication and collaboration, system error, lack of multidisciplinary approach, inadequate monitoring after a procedure and failure to take proper precautions.

In our case reports we showed one patient who was injured with a fatal outcome and another patient who developed health complications because of a delay in treatment. All of the reasons mentioned above did not exonerate the clinical doctors from their responsibility in the justice system. Cases of medical errors are processed through the civil court, whereas cases of gross negligence are handled by the criminal court. In most countries, the majority of the misdiagnosed gunshot wound cases are processed in the civil courts. In our two cases the convicted doctors were prosecuted under the criminal charge of reckless treatment of patients and gross negligence prescribed in the Criminal Code of Republic of North Macedonia under article 207. Article 207 reads that lack of diligence or care when administering treatment, inappropriate approach during diagnosis or treatment, regardless of whether it be on a conscious and voluntary basis or resulting from reckless omissions in the discharge of the doctor‘s legal duty having consequences to another party, does not release the doctor from guilt [13, 14].

Conclusion

Investigation of a possible incident of gunshot wound requires the collaboration of clinical doctors, forensic pathologists, radiologists, crime scene investigators, ballistics analysts and firearm examiners. When clinicians encounter atypical gunshot wound caused by the use of atypical ammunition, long-range shots, ricochet bullets or shots through solid material, they should be aware of certain features of the atypical entrance wound in order to diagnose and treat it promptly. Unlike typical gunshot wounds, the shape of atypical entrance wound can range from round to elliptical, large or even irregular with ragged, abraded margins. Furthermore, pseudo-stippling or pseudo- gunpowder tattooing around the bullet hole may be seen when the victim is near the ricochet target. Similarly, tumbling abrasions are produced when the bullet tumbles tangentially across the skin before entering the body. In the cases of a ricochet entrance wound, the bullet wipe is less pronounced compared to a direct shot [15, 16, 17].

It is important for the surgeons providing the treatment, to make careful excisions during surgical care of gunshot wounds and send them for histological analysis and tracing for gunshot residue particles, with a warning note not to put the excised tissue in alcohol or formalin to avoid the surface of the skin being washed.

Clinical doctors should pay close attention to the circumstances of the incident and obtain as much information from the patient, examine their clothes for any damage carefully handling them to avoid contamination [18]. Understanding and analysing the causes of medical errors is the only way of preventing them [19, 20].