Emedinews:Makesure:A patient with rheumatoid arthritis developed deformity.

Situation: A patient with rheumatoid arthritis developed deformity.

Reaction: Oh my God! why was treatment not started early?

Lesson: Make sure all patients with Rheumatoid Arthritis are started with specific treatments within 3 months of diagnosis.

Emedinews:Inspiration: One day I decided to quit...

I quit my job, my relationship, my spirituality. I wanted to quit my life. I went to the woods to have one last talk with God.

"God", I said. "Can you give me one good reason not to quit?"

His answer surprised me. "Look around", He said. "Do you see the fern and the bamboo?"

"Yes", I replied.

When I planted the fern and the bamboo seeds, I took very good care of them. I gave them light. I gave them water. The fern quickly grew from the earth. Its brilliant green covered the floor. Yet nothing came from the bamboo seed. But I did not quit on the bamboo.

In the second year the Fern grew more vibrant and plentiful. And again, nothing came from the bamboo seed. But I did not quit on the bamboo. He said.

"In the third year, there was still nothing from the bamboo seed. But I would not quit. In the fourth year, again, there was nothing from the bamboo seed. "I would not quit." He said. "Then in the fifth year a tiny sprout emerged from the earth.

Compared to the fern it was seemingly small and insignificant. But just 6 months later the bamboo rose to over 100 feet tall.

It had spent the five years growing roots.

Those roots made it strong and gave it what it needed to survive. I would not give any of my creations a challenge it could not handle."

He said to me. "Did you know, my child, that all this time you have been struggling, you have actually been growing roots."

"I would not quit on the bamboo. I will never quit on you. Don't compare yourself to others." He said. "The bamboo had a different purpose than the fern. Yet, they both make the forest beautiful."

Your time will come, "God said to me." You will rise high! "How high should I rise?" I asked.

How high will the bamboo rise?" He asked in return.

"As high as it can? I questioned.

"Yes." He said, "Give me glory by rising as high as you can.

I left the forest and bring back this story. I hope these words can help you see that God will never give up on you. He will never give up on you. Never regret a day in your life.

Emedinews:Makesure: A patient of suspected MI died after receiving sublingual nitrate.

Situation: A patient of suspected MI died after receiving sublingual nitrate.

Reaction: Oh my God! Why was a history of Viagra drug intake not taken?

Lesson: Make sure to take a history of Viagra drug intake before giving nitrates, because the two drugs co-administered can cause fatal fall in blood pressure.

Emedinews:Inspiration: Everyone is important

During Mark's first month of college, the professor gave his students a quiz. He was a conscientious student and had breezed through the questions, until he read the last one: "What is the first name of the woman who cleans the school?"

Surely this was some kind of joke, he had seen the cleaning woman several times. She was tall, dark-haired and in her 50s, but how would he know her name? He handed in his paper, leaving the last question blank.

Just before class ended, one student asked if the last question would count toward the quiz grade.

"Absolutely," said the professor. "In your careers, you will meet many people, all are significant. They each deserve your attention and care, even if all you do is smile and say 'hello'".

Mark never forgot that lesson, he also learned her name was Dorothy.

Emedinews:Insights on Medicolegal issues: Our issues have been in local newspapers for about last 6 months. There has been no result so far. What should we do now

Legal Question of the Day

(Prof. M C Gupta, Advocate & Medico-legal Consultant)

Q. Medical teachers in Gujarat are agitating for the following: 1-Pay according to sixth pay commission or UGC; 2-2. Time bound promotion; 3- Recognition of ad hoc service; 4-Removal of ceiling of pay; 5- Allowance as per Central Pay Commission rates; 6- Transparency in transfers; 7- No extra duties like VIP duties, Jail duties etc.; 8- No transfer to semi government colleges. A Notice was given to the government before going on strike. We have organised two rallies and two mass casual leave events. We have submitted 7 memoranda. Our issues have been in local newspapers for about last 6 months. There has been no result so far. What should we do now?

Ans.

1. Everybody takes doctors for granted. Doctors are often OK with that and hence the practice and suffering continues. A major reason for such continuance is that doctors do not know their legal rights and duties and manage everything themselves without getting legal opinion.

2. I suspect that your notice and memoranda were not drafted by a lawyer and hence the government is sitting pretty over them in the safe knowledge that they can be used against you.

3. It is possible that the HC may issue directions to end the strike either by taking suo moto action or if somebody petitions it. That will leave you nowhere.

4. You should do as follows:

A. Prepare a folder chronicling the developments and documents related to this strike and the previous similar movements over last 4-5 years.

B. Engage a good lawyer, pay him his fee, discuss the case with him, give him a copy of the folder, and ask him to give you legal opinion regarding:

1. Which of your demands are just and how much?

2. What is the next best course?

3. How to avoid a possible HC intervention and order to end the strike.   

Emedinews:Makesure:A foreigner presents with travelers diarrhea

Situation: A foreigner presents with travelers diarrhea

Reaction: Put him on ciprofloxacin

Lesson: Make sure that foreigner patients with travelers diarrhea are put on a course of ciprofloxacin and tinidazole

Emedinews:Inspiration: Daddy, how much do you make an hour?

With a timid voice and idolizing eyes, the little boy greeted his Father as he returned from work, "Daddy, how much do you make an hour?" Greatly surprised, but giving his boy a glaring look, the Father said: "Look, son, not even your mother knows that. Don't bother me now, I'm tired."

"But Daddy, just tell me please!? How much do you make an hour," the boy insisted. The Father finally giving up replied: “Twenty dollars per hour." "Okay, Daddy? Could you loan me ten dollars?" the boy asked.

Showing restlessness and positively disturbed, the Father yelled: "So that was the reason you asked how much I earn, right?? Go to sleep and don't bother me anymore!"

It was already dark and the Father was meditating on what he had said and was feeling guilty. He thought that his son wanted to buy something.

Finally, trying to ease his mind, the Father went to his son's room. "Are you asleep son?" asked the Father.

"No, Daddy. Why?" replied the boy partially asleep. "Here's the money you asked for earlier," the Father said.

"Thanks, Daddy!" rejoiced the son, while putting his hand under his pillow and removing some money.

"Now I have enough! I have twenty dollars!" the boy said to his Father.

The Father sat there, gazing at his son, confused at what his son just said. "Now Daddy could you sell me one hour of your time?"

Emedinews:Insights on Medicolegal issues: What is the treatment of poisonous bites and stings?

• Antivenom should only be given in a hospital or medical center where resuscitation can be given, because the patient may develop an allergic reaction. Antivenin should be used, if there are signs of severe systemic envenoming. It should not be used when there are no signs of systemic envenoming. To decide whether venom has been injected, and how serious the poisoning is, look for these signs:
• Swelling and local tissue injury at the site of the bite
• Blood that does not clot, causing bleeding from gums, nose, wounds and injection sites
• Shock caused by circulatory failure
• Neurotoxic paralysis (ptosis, ophthalmoplegia, dysarthria, peripheral muscle weakness, respiratory distress)
• Generalized muscle pain and local tissue damage
• Kidney failure, red or black urine
• Tender swollen lymph nodes near the bite site

• To test clotting time of whole blood: Place 2–3 ml of whole venous blood in a clean, dry, glass test–tube and leave undisturbed for 20 minutes at room temperature. Normal blood should have clotted by this time. Tip the tube to see if the blood is still liquid.
• If the wound becomes infected, treat as for any other local infection. Use antibiotics if needed.
• If there is local tissue injury, do not cover the wound, instead leave it open.

Emedinews:Makesure: A patient with acute chest pain died before reaching the hospital.

Situation: A patient with acute chest pain died before reaching the hospital.
Reaction: Oh my God! Why was water-soluble aspirin not given?
Lesson: Make sure that at the onset of acute heart attack and chest pain, water-soluble aspirin is chewed to reduce chances of sudden death.

Emedinews:Inspiration: Remembering Dad

When I was four years old: my daddy can do anything.

5 years old: My daddy knows a whole lot.

6 years old: My dad is smarter than your dad.

8 years old: my dad doesn’t know exactly everything.

10 years old: In the olden days, when my dad grew up, things were sure different.

12 years old: Oh, well, naturally, Dad doesn’t know anything about that, he is too old to remember his childhood.

14 years old: Don’t pay any attention to my dad, he is so old-fashioned.

21 years old: Him? my Lord, he’s hopelessly out of date.

25 years old: Dad knows about it, but then he should, because he has been around so long.

30 years old: Maybe we should ask Dad what he thinks, after all, he’s had a lot of experience.

35 years old: I’m not doing a single thing until I talk to Dad.

40y years old: I wonder how Dad would have handled it, he was so wise.

50 years old: I’d give anything if Dad were here now so I could talk this over with him.

Too bad I didn’t appreciate how smart he was, I could have learned a lot from him.

Emedinews:Insights on Medicolegal issues: False accusations of sexual assault

Allegations of sexual assault can be made easily, hard to prove but even harder to disprove

The sexual offenses which are recognized in our legal system are rape, sodomy, oral sex, drug-related sexual assault such as the molestation, inappropriate touching, forced kissing, forced oral, anal, vaginal penetration by fingering/fisting or any means, child sex abuse, sexual torture or any other form of complain as selling and buying of minor girls for illicit sexual intercourse, adultery, incest etc. In almost all of the above cases, a medical examination of accused and victim is required and the medical report as well as collected biological samples are very crucial and provide the strongest scientific evidence of the case since in crime of sexual offenses. An eye witness is rarely found.

The investigator/examining doctor should keep the possibility of false accusation of rape in mind and find out the truth. Medical examination must be conducted in a transparent manner in the interest of truth and justice without fear and favor as an obligation of medical ethics.

Emedinews:Makesure:A patient with human bite developed infection in the wound.

Situation: A patient with human bite developed infection in the wound.

Reaction: Oh my God! why were antibiotics not started in time?

Lesson: Make sure all patients with human bite are put early on amoxicillin-clavulanic group of antibiotics.

The Professor and the Jar

A professor stood before his philosophy class and had some items in front of him. When the class began, wordlessly, he picked up a very large and empty jar and proceeded to fill it with golf balls. He then asked the students if the jar was full. They agreed that it was. So the professor then picked up a box of small pebbles and poured them into the jar. He shook the jar lightly. The pebbles rolled into the open areas between the golf balls. He then asked the students again if the jar was full. They agreed it was.

The professor next picked up a box of sand and poured it into the jar. Of course, the sand filled up everything else. He asked once more if the jar was full. The students responded with a unanimous "Yes." The professor then produced two cans of beer from under the table and poured the entire contents into the jar, effectively filling the empty space between the sand. The students laughed.

"Now", said the professor, as the laughter subsided, "I want you to recognize that this jar represents your life. The golf balls are the important things - your family, your children, your health, your friends, your favorite passions - things that, if everything else was lost and only they remained, your life would still be full. The pebbles are the other things that matter like your job, your house, your car.

The sand is everything else - the small stuff. If you put the sand into the jar first" he continued, "there is no room for the pebbles or the golf balls. The same goes for life. If you spend all your time and energy on the small stuff, you will never have room for the things that are important to you. Pay attention to the things that are critical to your happiness. Play with your children. Take time to get medical checkups. Take your partner out to dinner. There will always be time to clean the house, and fix the rubbish. Take care of the golf balls first, the things that really matter. Set your priorities. The rest is just sand".

One of the students raised her hand and inquired what the beer represented. The professor smiled. "I'm glad you asked. It just goes to show you that, no matter how full your life may seem, there's always room for a couple of beers".

Emedinews:Insights on Medicolegal issues: False accusations of sexual assault

Allegations of sexual assault can be made easily, hard to prove but even harder to disprove

The sexual offenses which are recognized in our legal system are rape, sodomy, oral sex, drug-related sexual assault such as the molestation, inappropriate touching, forced kissing, forced oral, anal, vaginal penetration by fingering/fisting or any means, child sex abuse, sexual torture or any other form of complain as selling and buying of minor girls for illicit sexual intercourse, adultery, incest etc. In almost all of the above cases, a medical examination of accused and victim is required and the medical report as well as collected biological samples are very crucial and provide the strongest scientific evidence of the case since in crime of sexual offenses. An eye witness is rarely found.

The investigator/examining doctor should keep the possibility of false accusation of rape in mind and find out the truth. Medical examination must be conducted in a transparent manner in the interest of truth and justice without fear and favor as an obligation of medical ethics.

Emedinews:Makesure: An adult undergoing bronchoscopic biopsy developed infective endocarditis (IE).

Situation: An adult undergoing bronchoscopic biopsy developed infective endocarditis (IE).
Reaction: Oh my God! Why was IE prophylaxis not given?
Lesson: Make sure that all procedures of the respiratory tract that involve incision or biopsy of the respiratory mucosa include IE prophylaxis. 

Emedinews:Inspiration: Be Enthusiastic

Nothing great is ever achieved without enthusiasm. --Ralph Waldo Emerson

Enthusiasm and success go hand in hand, but enthusiasm comes first. Enthusiasm inspires confidence, raises morale, and builds loyalty! And is priceless. Enthusiasm is contagious. You can feel enthusiasm by the way a person talks, walks or shakes hands. Enthusiasm is a habit that one can acquire and practice.

Many decades ago, Charles Schwab, who was earning a salary of a million dollars a year, was asked if he was being paid such a high salary because of his exceptional ability to produce steel. Charles Schwab replied, "I consider my ability to arouse enthusiasm among the men the greatest asset I possess, and the way to develop the best that is in a man is by appreciation and encouragement."

Live while you are alive. Don't die before you are dead. Enthusiasm and desire are what change mediocrity to excellence.

Water turns into steam with a difference of only one degree in temperature and steam can move some of the biggest engines in the world.

That is what enthusiasm helps us to do in our lives.

Source: http://great-motivational-stories.blogspot.in/2008/05/be-enthusiastic.html

Emedinews:Insights on Medicolegal issues: Summon from court of law

The medical professional must keep in mind that the Criminal Courts have priority over Civil Courts. If a witness is summoned by two Courts on the same day, one of which is criminal and other civil, he should attend the Criminal Court and inform the Civil Court of his inability to attend, giving his reasons. Higher Courts have priority over the lower.

If he is summoned from two Courts of same status, he must attend the Court from where he received the summons first, informing the other Court about it. He can attend the second Court after finishing his evidence in the first Court.

Emedinews:Makesure:A 28–year–old male presents with increased frequency and occasional blood in urine. Examination of urine shows sterile pyuria

Situation: A 28–year–old male presents with increased frequency and occasional blood in urine. Examination of urine shows sterile pyuria.
Reaction: Oh my God! Why didn’t you check for TB?
Lesson: Make Sure to rule out TB in patients with frequency, dysuria, hematuria. Sterile pyuria is the first clue to diagnosis.

Emedinews:Inspiration: I knew you would come

There were two childhood buddies who went through school and college and even joined the army together. War broke out and they were fighting in the same unit. One night they were ambushed. Bullets were flying all over and out of the darkness came a voice, "Harry, please come and help me." Harry immediately recognized the voice of his childhood buddy, Bill.

He asked the captain if he could go. The captain said, "No, I can't let you go, I am already short-handed and I cannot afford to lose one more person. Besides, the way Bill sounds he is not going to make it." Harry kept quiet. Again the voice came, "Harry, please come and help me." Harry sat quietly because the captain had refused earlier.

Again and again the voice came. Harry couldn't contain himself any longer and told the captain, "Captain, this is my childhood buddy. I have to go and help." The captain reluctantly let him go. Harry crawled through the darkness and dragged Bill back into the trench. They found that Bill was dead. Now the captain got angry and shouted at Harry, "Didn't I tell you he was not going to make it? He is dead, you could have been killed and I could have lost a hand. That was a mistake." Harry replied, "Captain, I did the right thing. When I reached Bill he was still alive and his last words were “Harry, I knew you would come.”

Good relationships are hard to find and once developed should be nurtured. We are often told: Live your dream. But you cannot live your dream at the expense of others. People who do so are unscrupulous. We need to make personal sacrifices for our family, friends, and those we care about and who depend on us.

Emedinews:Insights on Medicolegal issues: WMA declaration of Malta on hunger strikers – Guidelines for medical management

The doctor must assess the mental capacity of the individual. This involves verifying that an individual intending to fast does not have a mental impairment that would seriously undermine the person's ability to make health care decisions. Individuals with seriously impaired mental capacity cannot be considered to be hunger strikers. They need to be given treatment for their mental health problems rather than allowed to fast in a manner that risks their health.

As early as possible, physicians should acquire a detailed and accurate medical history of the person who is intending to fast. The medical implications of any existing condition should be explained to the individual. Physicians should verify that hunger strikers understand the potential health consequences of fasting and forewarn them in plain language of the disadvantages. Physicians should also explain how damage to health can be minimized or delayed by, for example, increasing fluid intake. Since the person’s decisions regarding a hunger strike can be momentous, ensuring full patient understanding of the medical consequences is critical. Consistent with best practices for informed consent in health care, the physician should ensure that the patient understands the information conveyed by asking the patient to repeat back what they understand.

Emedinews:Makesure:A 40–year–old male developed acute heart attack after playing squash.

Situation: A 40–year–old male developed acute heart attack after playing squash.

Reaction: Oh my God! Why was a cardiac test not done?

Lesson: Make sure that anybody going for anaerobic games after the age of 40 should first get  a cardiac clearance.

Emedinews:Inspiration: A Pound of Butter

There was a farmer who sold a pound of butter to the baker. One day the baker decided to weigh the butter to see if he was getting a pound and he found that he was not. This angered him and he took the farmer to court. The judge asked the farmer if he was using any measure. The farmer replied, Your Honor, I am primitive. I don't have a proper measure, but I do have a scale."

The judge asked, "Then how do you weigh the butter?" The farmer replied "Your Honor, long before the baker started buying butter from me, I have been buying a pound loaf of bread from him. Every day when the baker brings the bread, I put it on the scale and give him the same weight in butter. If anyone is to be blamed, it is the baker."

What is the moral of the story? We get back in life what we give to others. Whenever you take an action, ask yourself this question: Am I giving fair value for the wages or money I hope to make? Honesty and dishonesty become a habit. Some people practice dishonesty and can lie with a straight face. Others lie so much that they don't even know what the truth is anymore. But who are they deceiving? Only themselves.

Emedinews:Insights on Medicolegal issues: Who is a surrogate medical decision maker for patient?

Studies suggest that spouses and other family members generally do not know the preferences of patients regarding the termination of life–sustaining treatments; therefore, they may not reach the same decision that the patient would have reached.1 One study found that even though patients believed both their family (87 %) and doctors (90 %) could accurately represent their wishes, neither family members nor doctors were able to adequately predict patient wishes on scenario testing with agreement ranging from 59 to 88 %.2 This discrepancy emphasizes the importance of patient/surrogate discussions about preference prior to a loss of capacity. Unfortunately, these proactive discussions are rare and clinicians are usually left relying on the family for decisions.
References
1. Emanuel EJ, Emanuel LL. Proxy decision making for incompetent patients: An ethical and empirical analysis. JAMA 1992;267:2067.
2. Shalowitz D, Garrett–Mayer E, Wendler D. The accuracy of surrogate decision–makers. Arch Intern Med 2006;166:493.

Emedinews:Makesure:A patient’s blood pressure was not responding on Arkamin.

Situation: A patient’s blood pressure was not responding on Arkamin.
Reaction: Oh my God! Why was the patient given Artamin?
Lesson: Make sure when writing the prescription that the drug name spelled clearly.

Emedinews:Inspiration: Credibility

We all know the story of the shepherd boy who cried wolf. The boy decided to have some fun at the expense of the villagers. He shouted, "Help, help, the wolf is here." The villagers heard him and came to his rescue. But when they got there, they saw no wolf and the boy laughed at them. They went away. The next day, the boy played the same trick and the same thing happened.

Then one day, while the boy was taking care of his sheep he actually saw a wolf and shouted for help. The people in the village heard him but this time nobody came to his rescue. They thought it was another trick and didn't trust him anymore. He lost his sheep to the wolf.

The moral of the story is - When people tell lies, they lose credibility. Once they have lost credibility, even when they tell the truth, no one believes them.

Make yourself an honest man and then you may be sure there is one rascal less in the world. Thomas Carlyle

Source: http://great-motivational-stories.blogspot.in/2008/06/credibility.html

Emedinews:Insights on Medicolegal issues: Is it necessary to disclose all information to patient? What is 'Therapeutic Privilege?

The patient has a right to full information, concerning diagnosis, treatment , prognosis, alternative treatments and its possible complications. 'Informed' means the consent of a patient to the performance of the health care services provided by a registered medical practitioner. There are 2 exceptions: No disclosure is required, if the patient indicates a preference not to be informed; or if the physician or surgeon believes that the patient is so anxiety prone or disturbed that the information would not be processed rationally or that it would probably cause significant psychological harm or it will cause adverse effect on patient's health. This exception to the legal duty of full disclosure to patient  is called the ‘therapeutic privilege’ of a doctor.

Emedinews:Makesure:A patient on dialysis and on oral antacid developed aluminum toxicity.

Situation: A patient on dialysis and on oral antacid developed aluminum toxicity.
Reaction: You should have put him on magaldrate preparations
Lesson: Magaldrate preparations do not cause aluminum toxicity in patients undergoing dialysis.

Emedinews:Inspiration: Why are Goals Important?

On the best sunny day, the most powerful magnifying glass will not light paper if you keep moving the glass. But if you focus and hold it, the paper will light up. That is the power of concentration.
A man was traveling and stopped at an intersection. He asked an elderly man, "Where does this road take me?" The elderly person asked, "Where do you want to go?" The man replied, "I don't know." The elderly person replied, “Then take any road. What difference does it make?"
How true. When we don't know where we are going, any road will take us there.
Suppose you have all the eleven football players, enthusiastically ready to play the game, all charged up, and then someone took the goal post away. What would happen to the game? There is nothing left. How do you keep score? How do you know you have arrived?
Enthusiasm without direction is like wildfire and leads to frustration. Goals give a sense of direction. Would you sit in a train or a plane without knowing where it was going? The obvious answer is no. Then why do people go through life without having any goals?

Emedinews:Insights on Medicolegal issues: Legal medicine: Doctor in witness box under oath

When a doctor is called in witness box of Court of Law, Oath has to be administered before he tenders his evidence.

A doctor as witness while administered the oath has to repeat, while standing… ‘the evidences which I shall give to the honorable court shall be the truth, the whole truth and nothing but the truth, so help me the almighty God".

If a Doctor wishes to give his evidences on solemn affirmation, he has to say that I solemnly affirm that the evidences which I shall give to the honorable court shall be the truth, the whole truth and nothing but the truth.The main objective of the oath is to find truthful statement and if any doctor/witness speaks a lie after administration of oath he is liable for punishment of perjury a criminal offence in our country as well as abroad. The Medical opinion of the doctor must be supported by reason/science and it is the reasons and not ipse dixit which is of importance in assesing the merit of the doctor’s opinion in the court of law.

Emedinews:Makesure:A-28-year old male presents with increased frequency and occasional blood in urine. Examination of urine shows sterile pyuria.

Situation: A-28-year old male presents with increased frequency and occasional blood in urine. Examination of urine shows sterile pyuria.
Reaction: Oh my God! Why didn’t you check for TB?
Lesson: Make Sure to rule out TB in patients with frequency, dysuria, hematuria. Sterile pyuria is the first clue to diagnosis.

Emedinews: Inspiration:The Midas Touch

 We all know the story of the greedy king named Midas. He had a lot of gold and the more he had the more he wanted. He stored all the gold in his vaults and used to spend time every day counting it.

One day while he was counting a stranger came from nowhere and said he would grant him a wish. The king was delighted and said, "I would like everything I touch to turn to gold." The stranger asked the king, Are you sure?" The king replied, "Yes." So the stranger said, "Starting tomorrow morning with the sun rays you will get the golden touch." The king thought he must be dreaming, this couldn't be true. But the next day when he woke up, he touched the bed, his clothes, and everything turned to gold. He looked out of the window and saw his daughter playing in the garden. He decided to give her a surprise and thought she would be happy. But before he went to the garden he decided to read a book. The moment he touched it, it turned into gold and he couldn't read it. Then he sat to have breakfast and the moment he touched the fruit and the glass of water, they turned to gold. He was getting hungry and he said to himself, "I can't eat and drink gold." Just about that time his daughter came running and he hugged her and she turned into a gold statue. There were no more smiles left.

The king bowed his head and started crying. The stranger who gave the wish came again and asked the king if he was happy with his golden touch. The king said he was the most miserable man. The stranger asked, "What would you rather have, your food and loving daughter or lumps of gold and her golden statue?" The king cried and asked for forgiveness. He said, "I will give up all my gold. Please give me my daughter back because without her I have lost everything worth having." The stranger said to the king, "You have become wiser than before" and he reversed the spell. He got his daughter back in his arms and the king learned a lesson that he never forget for the rest of his life.

Emedinews:Insights on Medicolegal issues: The greatest unsolved murder mysteries of all time was " How was Napoleon murdered"?

We know for a certainty where and when the famous French emperor Napoleon Bonaparte died: in exile on the island of St. Helena on May 5, 1821. And we know that he had been suffering a bladder infection for years and was prone to fainting. The official cause of death was listed as cancerous stomach ulcer? Yet nearly two century later opinion remains wildly split on what killed Napoleon. In 2001, the Strasbourg Forensic Institute examined strands of Napoleon hairs and showed that Napoleon had been exposed to major doses of arsenic and that raised a question, Was Napoleon assassinated? Will we ever know?

Emedinews:Makesure:A terminally ill patient who develops bed sores, is prescribed only systemic antibiotics.

Situation: A terminally ill patient who develops bed sores, is prescribed only systemic antibiotics.
Reaction: Please change the position of the patient frequently and keep the skin clean and dry.
Lesson: Make sure that good nursing care and maintenance of skin hygiene is advised first to patients with bed sores, along with topical antibiotics.

Emedinews:Inspiration: How Would You Like To Be Remembered?

About a hundred years ago, a man looked at the morning newspaper and to his surprise and horror, read his name in the obituary column. The news papers had reported the death of the wrong person by mistake. His first response was shock. Am I here or there? When he regained his composure, his second thought was to find out what people had said about him.
The obituary read, "Dynamite King Dies." And also "He was the merchant of death." This man was the inventor of dynamite and when he read the words "merchant of death," he asked himself a question, "Is this how I am going to be remembered?"
He got in touch with his feelings and decided that this was not the way he wanted to be remembered. From that day on, he started working toward peace. His name was Alfred Nobel and he is remembered today by the great Nobel Prize.
Just as Alfred Nobel got in touch with his feelings and redefined his values, we should step back and do the same.
What is your legacy? How would you like to be remembered? Will you be spoken well of? Will you be remembered with love and respect? Will you be missed?

Emedinews:Insights on Medicolegal issues: What is the Dr Hawley Harvey Crippen murder case?

The most notorious and famous murder case in British history

Hawley Harvey Crippen was hanged to death in London in one of the most notorious and famous murder cases in British history for the murder of his wife Cora Henrietta Crippen, on November 23, 1910 on the basis of forensic evidence. For nearly a century, Crippen, a doctor, was thought to have poisoned his wife with an obscure toxin, and buried. He was labeled "one of the most dangerous and remarkable men who have lived in this century." Researchers have now cast doubts on this conviction. Now forensic science at Michigan State University is producing evidence that his execution was a mistake. David Foran, a forensic expert and director of MSU’s forensic science program, partnering with clinical and forensic toxicologist John Harris Trestrail the managing director of the regional poison center in Grand Rapids, is combining state-of-the-art DNA analysis with solid sleuthing to show the remains buried in Crippen’s basement couldn’t have been his wife. 

Emedinews:Insights on Medicolegal issues: What is the Dr Hawley Harvey Crippen murder case?

The most notorious and famous murder case in British history

Hawley Harvey Crippen was hanged to death in London in one of the most notorious and famous murder cases in British history for the murder of his wife Cora Henrietta Crippen, on November 23, 1910 on the basis of forensic evidence. For nearly a century, Crippen, a doctor, was thought to have poisoned his wife with an obscure toxin, and buried. He was labeled "one of the most dangerous and remarkable men who have lived in this century." Researchers have now cast doubts on this conviction. Now forensic science at Michigan State University is producing evidence that his execution was a mistake. David Foran, a forensic expert and director of MSU’s forensic science program, partnering with clinical and forensic toxicologist John Harris Trestrail the managing director of the regional poison center in Grand Rapids, is combining state-of-the-art DNA analysis with solid sleuthing to show the remains buried in Crippen’s basement couldn’t have been his wife. 

Emedinews:Makesure:A patient after receiving 40 units of insulin developed severe hypoglycemia.

Situation: A patient after receiving 40 units of insulin developed severe hypoglycemia.
Reaction: Oh my God! The order was for 4 units.
Lesson: Make sure that 4 unit is not written as 4.0 units.

Emedinews:Inspiration: It is the little things that make a big difference

There was a man taking a morning walk at the beach. He saw that along with the morning tide came hundreds of starfish and when the tide receded, they were left behind and with the morning sun rays, they would die. The tide was fresh and the starfish were alive. The man took a few steps, picked one and threw it into the water. He did that repeatedly.

Right behind him there was another person who couldn't understand what this man was doing. He caught up with him and asked, "What are you doing? There are hundreds of starfish. How many can you help? What difference does it make?"

This man did not reply, took two more steps, picked up another one, threw it into the water, and said, "It makes a difference to this one."

What difference are we making? Big or small, it does not matter. If everyone made a small difference, we'd end up with a big difference, wouldn't we?

Emedinews:Inspiration: SMART Goals

If you ask most people what is their one major objective in life, they would probably give you a vague answer, such as, "I want to be successful, be happy, make a good living," and that is it. They are all wishes and none of them are clear goals.

Goals must be SMART:

S--Specific. For example, "I want to lose weight." This is wishful thinking. It becomes a goal when I pin myself down to "I will lose 10 pounds in 90 days."

M--Measurable. If we cannot measure it, we cannot accomplish it. Measurement is a way of monitoring our progress.

A--Achievable. Achievable means that it should be out of reach enough to be challenging but it should not be out of sight, otherwise it becomes disheartening.

R--Realistic. A person who wants to lose 50 pounds in 30 days is being unrealistic.

T--Time-bound. There should be a starting date and a finishing date.

Emedinews:Makesure:A 62–year–old–diabetic with coronary artery disease, on treatment for the same, came for follow up.

Situation: A 62–year–old–diabetic with coronary artery disease, on treatment for the same, came for follow up.

Reaction: Oh my God! Why did not you put him on antioxidants!!

Lesson: Make Sure to add antioxidants to the prescription because of their free radical scavenging and other beneficial effects.

Emedinews:Insights on Medicolegal issues: Summons from court of law

The word ‘Summon’ is derived from ‘subpoena’ which means under penalty.

Summon is a court document/order compelling the attendance of any witness including doctor as medical witness, in a Court of law on a particular day, time and place, for the purpose of giving evidence. It may also require him to bring with him the medicolegal report/clinical sheets/register, any medical books, medical documents etc, that he is bound by law to produce in evidence. The summon is issued under Section 61 of Criminal Procedure Code by the Court in writing, in duplicate, signed by the presiding officer of the Court and bears the seal of the Court. It is served on the witness by a police officer, by an officer of the Court or other public servant. The person should sign a receipt on the back of the other copy. It can also be served by registered post, or fixed on some conspicuous part of his residence.

Emedinews:Insights on Medicolegal issues: What is the medical treatment of chemical contamination and burn?

• In case of chemical contamination or burn injury of eye, put fluorescein drops in the eye. Burns will stain yellow.
• If there are yellow stains with fluorescein, put chloramphenicol 1% eye ointment in the eye. Put more ointment into the eye every two hours. Continue until the eye is no longer red and the sclera is white, and then for another 24 hours.
• If the pain is severe the patient may need an intramuscular injection of morphine.
• If there is no water nearby dab or gently wipe the skin and hair with cloth or paper.
• Immediately wash the affected part of the body under cold or lukewarm running water, using soap if you have some. If there is no running water use buckets of water. Do it quickly and use a lot of water. Wear gloves and an apron if needed, to protect you from splashes of chemical. Some chemicals give off vapors: be careful not to breathe in vapors.
• Quickly remove any of the patient’s clothes contaminated with chemical or vomit, as well as shoes and wrist watch if necessary. Speed is important. Cut the clothes off if the chemicals are very poisonous or corrosive.
• If large areas of the body are contaminated with chemical, wash the patient under a shower or a hose. Remember to clean the hair and under the fingernails, in the groin and behind the ears, if necessary.
• Continue to pour water over the patient for 10 minutes or longer if you can still see chemicals on the skin. If the skin feels sticky or soapy, wash it until the feeling disappears. This may take an hour or more.
• Make sure the water drains away freely and safely as it will have chemical in it.
• Do not rub or scrub the skin.
• Dry the skin gently with a clean, soft towel. If clothing stays stuck to the skin even after water has been poured over it, do not remove it.
• Remember that many chemicals can pass through the skin very quickly. Look for signs of poisoning.

Emedinews:Inspiration:Juggle Balls

Imagine life as a game in which you are juggling some five balls in the air. You name them – work, family, health, friends and spirit and you’re keeping all of these in the air. You will soon understand that work is a rubber ball. If you drop it, it will bounce back. But the other four balls – family, health, friends and spirit are made of glass. If you drop one of these, they will be irrevocably scuffed, marked, nicked, damaged or even shattered. They will never be the same. You must understand that and strive for balance in your life. How?

• Don’t undermine your worth by comparing yourself with others. It is because we are different that each of us is special.
• Don’t set your goals by what other people deem important. Only you know what is best for you.
• Don’t take for granted the things closest to your heart. Cling to them as you would your life, for without them, life is meaningless.
• Don’t let your life slip through your fingers by living in the past or for the future. By living your life one day at a time, you live ALL the days of your life.
• Don’t give up when you still have something to give. Nothing is really over until the moment you stop trying.
• Don’t be afraid to admit that you are less than perfect. It is this fragile thread that binds us each together.
• Don’t be afraid to encounter risks. It is by taking chances that we learn how to be brave.
• Don’t shut love out of your life by saying it’s impossible to find. The quickest way to receive love is to give; the fastest way to lose love is to hold it too tightly; and the best way to keep love is to give it wings.
• Don’t run through life so fast that you forget not only where you’ve been, but also where you are going.
• Don’t forget that a person’s greatest emotional need is to feel appreciated.
• Don’t be afraid to learn. Knowledge is weightless, a treasure you can always carry easily.
• Don’t use time or words carelessly. Neither can be retrieved. Life is not a race, but a journey to be savored each step of the way.

Emedinews:Insights on Medicolegal issues: World Medical Association (WMA) guidelines for medical doctors in biomedical research involving human subjects

• Doctors should abstain from engaging in research projects involving human subjects unless they are satisfied that the hazards involved are believed to be predictable. Doctors should cease any investigation if the hazards are found to outweigh the potential benefits.
• In publication of the results of his or research, the doctor is obliged to preserve the accuracy of the results. Reports of experimentation not in accordance with the principles laid down in this Declaration should not be accepted for publication.
• In any research on human beings, each potential subject must be adequately informed of the aims, methods, anticipated benefits and potential hazards of the study and the discomfort, it may entail. He or she should be informed that he or she is at liberty to abstain from participation in the study and that he or she is free to withdraw his or her consent to participation at any time. The doctor should then obtain the subject’s freely given informed consent, preferably in writing.
• When obtaining informed consent for the research project the doctor should be particularly cautious if the subject is in a dependent relationship to him or her or may consent under duress. In that case the informed consent should be obtained by a doctor who is not engaged in the investigation and who is completely independent of this official relationship.
• In case of legal incompetence, informed consent should be obtained from the legal guardian in accordance with national legislation. Where physical or mental incapacity makes it impossible to obtain informed consent, or when the subject is a minor, permission from the responsible relative replaces that of the subject in accordance with national legislation.
• The research protocol should always contain a statement of the ethical consideration involved and should indicate that the principles enunciated in the present Declaration are complied with.

(Ref: 18th World Medical Assembly, Helsinki, Finland, 1964 and revised by the 29th World Medical Assembly, Tokyo, Japan, 1975).

Emedinews:Makesure:A patient with fever and cough develops complications after he was given antibiotics.

Situation: A patient with fever and cough develops complications after he was given antibiotics.

Reaction: Oh my God! What was the need of giving the antibiotics?

Lesson: Make sure a patient with fever and cough is not given antibiotics as presence of cough is mostly due to viral infection.

Emedinews:Inspiration: Story of Appreciation

One young academically excellent person went to apply for a managerial position in a big company. He passed the first interview, the director did the last interview, made the last decision. The director discovered from the CV that the youth's academic achievements were excellent all the way, from the secondary school until the postgraduate research, never had a year when he did not score.

The director asked, “Did you obtain any scholarships in school?" the youth answered "None".

The director asked, " Was it your father who paid for your school fees?"

The youth answered, "My father passed away when I was one year old, it was my mother who paid for my school fees.

The director asked,  " Where did your mother work?" The youth answered,  "My mother worked as clothes cleaner.

The director requested the youth to show his hands. The youth showed a pair of hands that were smooth and perfect.

The director asked, " Have you ever helped your mother wash the clothes before?"

The youth answered, “Never, my mother always wanted me to study and read more books. Furthermore, my mother can wash clothes faster than me.”

The director said, "I have a request. When you go back today, go and clean your mother's hands, and then see me tomorrow morning.

The youth felt that his chance of landing the job was high. When he went back, he happily requested his mother to let him clean her hands. His mother felt strange, happy but with mixed feelings, she showed her hands to the kid.

The youth cleaned his mother's hands slowly. His tear fell as he did that. It was the first time he noticed that his mother's hands were so wrinkled, and there were so many bruises in her hands. Some bruises were so painful that his mother shivered when they were cleaned with water.

This was the first time the youth realized that it was this pair of hands that washed the clothes everyday to enable him to pay the school fee. The bruises in the mother's hands were the price that the mother had to pay for his graduation, academic excellence and his future. After finishing the cleaning of his mother's hands, the youth quietly washed all the remaining clothes for his mother. That night, mother and son talked for a very long time.

Next morning, the youth went to the director's office. The Director noticed the tears in the youth's eyes, asked: " Can you tell me what have you done and learned yesterday in your house?"

The youth answered, " I cleaned my mother's hand, and also finished cleaning all the remaining clothes'

The Director asked, " please tell me your feelings."

The youth said, “Number 1, I know now what is appreciation. Without my mother, there would not the successful me today. Number 2, by working together and helping my mother, only I now realize how difficult and tough it is to get something done.  

Number 3, I have come to appreciate the importance and value of family relationship.”

The director said, "This is what I am looking for to be my manager. I want to recruit a person who can appreciate the help of others, a person who knows the sufferings of others to get things done, and a person who would not put money as his only goal in life. You are hired.

Later on, this young person worked very hard, and received the respect of his subordinates. Every employee worked diligently and as a team. The company's performance improved tremendously.

A child, who has been protected and habitually given whatever he wanted, would develop "entitlement mentality" and would always put himself first. He would be ignorant of his parent's efforts. When he starts work, he assumes that every person must listen to him, and when he becomes a manager, he would never know the sufferings of his employees and would always blame others.

For this kind of people, who may be good academically, may be successful for a while, but eventually would not feel sense of achievement. He will grumble and be full of hatred and fight for more. If we are this kind of protective parents, are we really showing love or are we destroying the kid instead?

Emedinews:Makesure:A patient with rheumatic arthritis was not given penicillin prophylaxis, and subsequently developed another attack.

Situation: A patient with rheumatic arthritis was not given penicillin prophylaxis, and subsequently developed another attack.

Reaction: Oh my God! Why was the prophylaxis not started?

Lesson: Make sure that one administers secondary prophylaxis in the setting of suspected poststreptococcal reactive arthritis for up to one year after the onset of symptoms. Evidence of valvular disease after one year should prompt continued prophylaxis; otherwise, antibiotic prophylaxis may be discontinued.

Emedinews: Inspiration: Prison help!

An old man lived alone in Minnesota. He wanted to spade his potato garden, but it was very hard work. His only son, who would have helped him, was in prison. The old man wrote a letter to his son and mentioned his situation:
Dear Son,
I am feeling pretty bad because it looks like I won’t be able to plant my potato garden this year. I hate to miss doing the garden because your mother always loved planting time. I’m just getting too old to be digging up a garden plot. If you were here, all my troubles would be over. I know you would dig the plot for me, if you weren’t in prison.
Love, Dad
Shortly, the old man received this telegram: ‘For Heaven’s sake, Dad, don’t dig up the garden!! That’s where I buried the GUNS!!’
At 4 a.m. the next morning, a dozen FBI agents and local police officers showed up and dug up the entire garden without finding any guns.
Confused, the old man wrote another note to his son telling him what had happened, and asked him what to do next. His son’s reply was: ‘Go ahead and plant your potatoes, Dad. It’s the best I could do for you, from here.’
Moral: No matter where you are in the world, if you have decided to do something deep from your heart, you can do it. It is the thought that matters, not where you are or where the person is.
Source: http://academictips.org/blogs/prison-help/

Emedinews:Insights on Medicolegal issues: The name Morphine originates from the Morpheus - the Greek God of dreams

·        Morphine is an alkaloid of opium - white crystals, with a bitter taste and alkaline reaction. It is very sparingly soluble in cold water but soluble in boiling water.

·        Morphine hydrochloride and morphine sulfate are medicinal preparations and morphine acetate is a non-official preparation, the dose of each being 8 to 20 mg. These salts are bitter in taste, neutral in reaction and are 5 to 8 times more powerful than opium.

·        Morphine has a depressant action on the cortex, the respiratory and cough centers in the medulla are depressed but the vagus and vomiting centers are stimulated.

·        The spinal cord is also stimulated. Its most outstanding effect is relief of pain, partly due to depression of the pain perception in cerebral area and partly due to its euphoric effect. 

Emedinews:Makesure:A patient who had blood in the urine one month back was found to have large bladder cancer.

Situation: A patient who had blood in the urine one month back was found to have large bladder cancer. Reaction: Oh my God! why was a cystoscopy not done at that time?
Lesson: Make sure that all cases of painless bleeding in the urine are investigated for cancer at the time of first presentation.

Emedinews: Inspiration: A lesson in heart

My little 10-year-old daughter, Sarah was born with a muscle missing in her foot and wears a brace all the time. She came home one beautiful spring day to tell me she had competed in “field day” – that’s where they have lots of races and other competitive events.
Because of her leg support, my mind raced as I tried to think of encouragement for my Sarah, things I could say to her about not letting this get her down – but before I could say anything, she said, “Daddy, I won two of the races!” I couldn’t believe it! And then Sarah said, “I had an advantage.” I knew it. I thought she must have been given a head start…some kind of physical advantage. But again, before I could say anything, she said, “Daddy, I didn’t get a head start…my advantage was I had to try harder!”

Emedinews:Insights on Medicolegal issues: WMA declaration of Malta on hunger strikers – Guidelines for medical management

Physicians need to satisfy themselves that food or treatment refusal is the individual’s voluntary choice. Hunger strikers should be protected from coercion. Physicians can often help to achieve this and should be aware that coercion may come from the peer group, authorities or others, such as family members. Physicians or other health care personnel may not apply undue pressure of any sort on the hunger striker to suspend the strike. Treatment or care of the hunger striker must not be conditional upon suspension of the hunger strike. If a physician is unable for reasons of conscience to abide by a hunger striker’s refusal of treatment or artificial feeding, the physician should make this clear at the outset and refer the hunger striker to another physician who is willing to abide by the hunger striker’s refusal.

Emedinews:Inspiration: Teamwork Lesson

When you see geese flying along in “V” formation, you might consider what science has discovered as to why they fly that way. As each bird flaps its wings, it creates an uplift for the bird immediately following. By flying in “V” formation, the whole flock adds at least 71 percent greater flying range than if each bird flew on its own. People who share a common direction and sense of community can get where they are going more quickly and easily because they are traveling on the thrust of one another.

When a goose falls out of formation, it suddenly feels the drag and resistance of trying to go it alone - and quickly gets back into formation to take advantage of the lifting power of the bird in front. If we have as much sense as a goose, we will stay in formation with those people who are headed the same way we are.

When the head goose gets tired, it rotates back in the wing and another goose flies point. It is sensible to take turns doing demanding jobs, whether with people or with geese flying south. Geese honk from behind to encourage those up front to keep up their speed.

What messages do we give when we honk from behind? Finally - and this is important - when a goose gets sick or is wounded by gunshot, and falls out of formation, two other geese fall out with that goose and follow it down to lend help and protection. They stay with the fallen goose until it is able to fly or until it dies, and only then do they launch out on their own, or with another formation to catch up with their group.

 If we have the sense of a goose, we will stand by each other like that.

 Source: http://academictips.org/blogs/the-goose-story-teamwork-lesson/

Emedinews:Insights on Medicolegal issues: Cross–examination Debate For Standards Of Medical Care

The cross–examination format involves eight speeches and four cross–examination sessions. The first four speeches are designated as constructive speeches. These are longer speeches, and are open to new lines of argument at any point in time. The final four speeches are designated as rebuttal speeches. These shorter speeches are reserved for summaries, which mean they are not open to new lines of argument. Interspersed between the constructive speeches are short cross–examination sessions, in which the debater who has just finished speaking is questioned by an opponent. During the course of the medical debate, each debater will deliver a constructive speech, a rebuttal speech, be cross–examined by an opponent and cross–examine an opponent. The order of speech is arranged to give the affirmative the open and closing speeches in the debate. 

Emedinews:Makesure:A patient with uncomplicated gonorrhea comes to hospital for treatment.

Situation: A patient with uncomplicated gonorrhea comes to hospital for treatment.
Reaction: Oh my God! Why did I advise ampicillin to this patient?
Lesson: Make sure to remember that cure can be elicited by administering oral doxycycline to patients with uncomplicated gonorrhoea.

Emedinews: Inspiration:True friend

Horror gripped the heart of the World War I soldier as he saw his lifelong friend fall in battle. Caught in a trench with continuous gunfire whizzing over his head, the soldier asked his lieutenant if he might go out into the “no man’s land” between the trenches to bring his fallen comrade back.

“You can go,” said the lieutenant, “but I don’t think it will be worth it. Your friend is probably dead and you may throw your life away.” The lieutenant’s advice didn’t matter, and the soldier went anyway. Miraculously he managed to reach his friend, hoist him onto his shoulder and bring him back to their company’s trench. As the two of them tumbled in together to the bottom of the trench, the officer checked the wounded soldier, and then looked kindly at his friend.

“I told you it wouldn’t be worth it,” he said. “Your friend is dead and you are mortally wounded.” “It was worth it, though, sir,” said the soldier. “What do you mean, worth it?” responded the Lieutenant. “Your friend is dead.”

“Yes, Sir” the private answered. “But it was worth it because when I got to him, he was still alive and I had the satisfaction of hearing him saying, “Jim…, I knew you’d come.”

Many times in life, whether a thing is worth doing or not, really depends on how you look at it. Take up all your courage and do something your heart tells you to do so that you may not regret not doing it later in your life. May each and every one of you be blessed with the company of true friends.

A true friend is one who walks in, when the rest of the world walks out. War doesn’t determine who’s right. War only determines who’s left.

 Source: http://academictips.org/blogs/military-story-true-friend/

Emedinews:Insights on Medicolegal issues: Exposure to a poison leads to illness

The very old, very young or those in poor health suffer greater damage

When people are in contact with a poison they are said to be exposed to it. The effect of exposure depends partly on how long the contact lasts and how much poison gets into the body, and partly on how much poison the body can get rid of during this time. Exposure may happen only once or many times.  

• Acute exposure is a single contact that lasts for seconds, minutes or hours, or several exposures over about a day or less.
• Chronic exposure is contact that lasts for many days, months or years. It may be continuous or broken by periods when there is no contact. Exposure that happens only at work, for example, is not continuous. Chronic exposure to small amounts of poison may not cause any signs or symptoms of poisoning at first. It may be many days or months before there is enough chemical inside the body to cause poisoning. For example, a person may use pesticide every day. Each day the person is exposed to only a small amount of pesticide, but the amount of pesticide in the body gradually builds up, until eventually, after many days, it adds up to a poisonous dose. Only then does the person begin to feel unwell. 

Emedinews:Makesure: A patient with angina and abnormal endothelial functions was put on atenolol.

Situation: A patient with angina and abnormal endothelial functions was put on atenolol.
Reaction: Oh my God! Why you did not consider nebivolol?
Lesson: Make sure that nebivolol is used as the beta blocker of choice in patients with proven endothelial dysfunction (Kardiologiia 2004;44(2):15–18).

Emedinews:Inspiration: An act of kindness

Years ago, when my then husband had been made redundant, I was pregnant with our second child and our daughter was only 10 months old.

We were on benefits for the first time in our lives - even the baby milk was free - and our mortgage was being paid. Our pride was in our boots. A free supermarket bus used to drop off people outside our house and a lady got off the bus and came down our drive with two bags of shopping for us. She said she hoped I didn't mind but she'd heard of our troubles from some of the neighbors and had bought us a chicken, fresh cream, cakes and biscuits to help us out.

I stood on the doorstep and cried at her kindness. I offered to pay but she wouldn't hear of it and said I'd have the opportunity to do the same for someone else one day when our fortunes took a turn for the better.

I've done the same more than once and I'll never forget the stranger who knocked on my door with free shopping for me and my family in our time of need.

Emedinews:Insights on Medicolegal issues: What is the nature of bullet wounds of the head?

In most cases of these injuries, the bullet passes completely through the skull. As it enters the skull, it produces a clean cut hole in the outer table and a larger hole in the inner table. At the exit point, these conditions are reversed and the hole in the outer table is larger than the hole in the inner table. These facts are often of importance in determining the direction of fire in bullet injuries of the head. The track of a bullet through the brain tissues varies greatly, depending on the range and stability of the bullet. On the other hand, if it remains high velocity at the time of impact with the skull, there may be considerable damage from the cavitation effect within the skull.

• Fissured fractures often radiate through the vault and base of the skull from the bullet entrance and exit holes.
• In certain bullet injuries of the head, the bullet may fail to emerge from the skull and in these cases an area of bony comminuting is often found at the site of lodgment.
• When a bullet strikes the head at a tangent, penetration of the skull may fail to occur, but the force of the bullet may be sufficient to fragment the inner table at the site of impact. Delayed pressure effects and cranial edema may be produced as a result of this.