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Wound and injury awareness amongst students and doctors
Journal of Clinical Forensic Medicine (2003) 10, 231–234 Ó 2003 Elsevier Ltd and AFP. All rights reserved. doi:10.1016/S1353-1131(03)00108-1
ORIGINAL COMMUNICATION
Wound and injury awareness amongst students and doctors R. Jones Department of Surgery, Queen Elizabeth Hospital, Woolwich, London, UK SUMMARY Introduction: Concern has been raised in the medical press regarding the inability of doctors to describe wounds and injuries of medico-legal significance correctly. Methods: Medical students and doctors of all grades, from the Department of Surgery at a London teachinghospital affiliated unit were shown a series of photographs illustrating wounds and injuries expected to be encountered in emergency medical practice. They were asked to identify the type of wound or injury as well as the manner in which that injury may have been caused. Result: The results indicated that students and doctors of all grades in this unit were not confident at identifying wounds and injuries, using the correct terminology. The term ‘laceration’ was widely used to describe incised wounds, and vice versa. Gun shot wounds were poorly identified as such, and were only correctly described by those who clearly ‘knew’ what they were looking at. Conclusion: In order to provide doctors with the skills with which they need to correctly describe wounds and injuries encountered in an emergency setting, this author proposes the introduction of specific teaching in wound identification at undergraduate and postgraduate levels. Ó 2003 Elsevier Ltd and AFP. All rights reserved. Journal of Clinical Forensic Medicine (2003) 10, 231–234
(PRHOs), Senior House Officers (SHOs), Registrars and Consultants in the Department of Surgery, Queen Elizabeth Hospital Woolwich between December 2002 and January 2003. The photographs were identified from WebPath3 and PathGuy4 – internet resources for general and forensic pathology. The research subject completed a structured questionnaire and the results analysed by the author. For each photograph, the subject was asked what type of wound/injury was illustrated, and how it might have been caused i.e., the mechanism of injury.
AIM To determine the level of awareness of a selection of wound types commonly encountered in clinical practice, and having medico-legal importance, amongst final year medical students and doctors working in a London teaching hospital setting.
METHODS A series of 6 photographs depicting wounds likely to be encountered in clinical practice (particularly in an emergency medicine/trauma setting) were shown to final year students, Pre Registration House Officers
RESULTS A total of 52 subjects took part in the study. There were 16 final year medical students, 10 PRHOs, 10 SHOs, 7 Registrars and 9 Consultants.
––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Dr. R. Jones MBBS, BSc.(Hons), Department of Surgery, Queen Elizabeth Hospital, Woolwich, 18 Speldhurst Road, Hackney, London E9 7EH, UK.
Photograph 1. Abrasion on an elbow Overall the cause of the wound was recognised by nearly 80%, but a large proportion of most grades
Correspondence to: Dr. R. Jones MBBS, BSc.(Hons). Tel.: +44-208986-8296. 231
232 Journal of Clinical Forensic Medicine Table 1 Responses by grade to photograph 1 (Abrasion) Type
Medical student PRHO SHO Registrar Consultant Total
Cause
Correct (%)
Incorrect (%)
Total
Correct (%)
Incorrect (%)
Total
13 (81) 5 (50) 5 (50) 7 (100) 7 (71) 37 (71)
3 (19) 5 (50) 5 (50) 0 2 (22) 15 (29)
16 10 10 7 9 52
12 (75) 7 (70) 7 (70) 7 (100) 8 (89) 41 (79)
4 (25) 3 (30) 3 (30) 0 1 (11) 11 (21)
16 10 10 7 9 52
could not ascribe the type of wound illustrated, and some incorrect terms used included a bruise and even a tangential bullet wound (Table 1). Photograph 2. A stab wound made by a single edged blade The incorrect use of terminology represented the biggest failure amongst all grades of respondents in this section – only 38% correctly identified the wound as a stab wound, most calling it a laceration. Causation was answered well – varying from 81 to 100% (90% overall) (Table 2). Photograph 3. Multiple lacerations of the hand (caused by a punch through heavy glazing) If ‘crush’ injury or ‘heavy machinery accident’ were excluded, this photograph was poorly identified by all grades of respondents. However, if these terms were
accepted, the following results were obtained; (see Table 3). Two thirds of respondents could correctly identify these injuries as involving some element of blunt trauma i.e., crush injuries, whilst the causation suggested by respondents universally involved heavy machinery or ‘mangling’ – few suggested any other form of blunt trauma, and none of the respondents suggested punching a hard object as a possible means of causation. The term laceration was used by 29% of respondents. Photograph 4. Close range (soft contact, low velocity) gun shot entry wound In general, this photograph elicited correct responses as to type and causation by those who ‘knew’ what they were looking at. Some respondents did not complete the ‘type of wound’ box for this photograph, but correctly identified the cause.
Table 2 Responses by grade to photograph 2 (Stab wound with single edged blade) Type
Medical student PRHO SHO Registrar Consultant Total
Cause
Correct (%)
Incorrect (%)
Total
Correct (%)
Incorrect (%)
Total
6 (38) 2 (20) 6 (60) 2 (29) 4 (44) 20 (38)
10 (62) 8 (80) 4 (40) 5 (71) 5 (66) 32 (62)
16 10 10 7 9 52
13 (81) 10 (100) 9 (90) 7 (100) 8 (89) 47 (90)
3 0 1 0 1 5
16 10 10 7 9 52
(19) (10) (11) (10)
Table 3 Responses by grade to photograph 3 (Multiple hand lacerations) Type
Medical student PRHO SHO Registrar Consultant Total
Cause
Correct (%)
Incorrect (%)
Total
Correct (%)
Incorrect (%)
Total
11 5 8 3 8 35
5 5 2 4 1 17
16 10 10 7 9 52
11 9 7 3 9 39
5 1 3 4 0 13
16 10 10 7 9 52
(67) (50) (80) (43) (89) (67)
(33) (50) (20) (57) (11) (33)
(67) (90) (70) (43) (100) (75)
(33) (10) (30) (57) (25)
Wound and injury awareness 233 Table 4 Responses by grade to photograph 4 (close range gunshot entrance wound) Type
Medical student PRHO SHO Registrar Consultant Total
Cause
Correct (%)
Incorrect (%)
Total
Correct (%)
Incorrect (%)
Total
4 (25) 5 (50) 7 (70) 5 (71) 7 (78) 28 (54)
12 (75) 5 (50) 3 (30) 2 (29) 2 (22) 24 (46)
16 10 10 7 9 52
5 (31) 6 (60) 7 (70) 5 (71) 7 (78) 30 (58)
11 (69) 4 (40) 3 (30) 2 (29) 2 (22) 22 (42)
16 10 10 7 9 52
Incorrect responses varied from ‘cigarette burn’, to melanoma, whilst one respondent thought this wound was an insect bite (Table 4).
(or deliberate self-harm). None suggested the term ‘defensive wounds’ (Table 5). Photograph 6. Hard Contact (low velocity) gunshot entrance wound with stellate skin splitting at the wound edges
Photograph 5. Incised (defensive) wounds on forearm The use of the term laceration predominated, and was followed by a correct response to causation by the majority of respondents – i.e., sharp force trauma. Many suggested that the wounds were self-inflicted
As with photograph 4 of the close range gunshot entrance wound, respondents correctly identifying the type of wound also identified the mechanism of
Table 5 Responses by grade to photograph 5 (Incised wounds on forearm (defensive wounds)) Type
Medical student PRHO SHO Registrar Consultant Total
Cause
Correct (%)
Incorrect (%)
Total
Correct (%)
Incorrect (%)
Total
5 (31) 1 (10) 2 (20) 1 (14) 1 (11) 10 (19)
11 (69) 9 (90) 8 (80) 6 (86) 8 (89) 42 (81)
16 10 10 7 9 52
13 (81) 10 (100) 9 (90) 5 (71) 9 (100) 46 (88)
3 0 1 2 0 6
16 10 10 7 9 52
(19) (10) (29) (12)
Table 6 Responses by grade to photograph 6 (Hard contact gunshot entrance wound) Type
Medical student PRHO SHO Registrar Consultant Total
Cause
Correct (%)
Incorrect (%)
Total
Correct (%)
Incorrect (%)
Total
6 (38) 3 (30) 1 (10) 1 (14) 4 (44) 15 (29)
10 (62) 7 (70) 9 (90) 6 (86) 5 (56) 37 (71)
16 10 10 7 9 52
6 (38) 3 (30) 1 (10) 1 (14) 4 (44) 15 (29)
10 (62) 7 (70) 9 (90) 6 (86) 5 (56) 37 (71)
16 10 10 7 9 52
Table 7 Summary table of responses by grade for all photographs Wound type
Abrasion Stab wound Multiple lacerations Close range gunshot entrance wound Incised wounds (defensive) Contact gunshot entrance wound
Type
Cause
Correct (%)
Incorrect (%)
Correct (%)
Incorrect (%)
71 38 67 54 19 29
29 62 33 46 81 71
79 90 75 58 88 29
21 10 25 42 12 71
234 Journal of Clinical Forensic Medicine wounding correctly, and ‘knew’ what they were looking at. For the majority, this photograph caused the most difficulty of them all (Table 6). Incorrect terms included, ‘abscess’, ‘burn’, ‘pyoderma gangrenosum’ and ‘blunt trauma’. Table 7 illustrates a summary of all responses by wound type and grade.
DISCUSSION The ability to recognise and interpret wounds and injuries is an important skill that should be within the capabilities of all practicing medical graduates. Even the most junior doctors in the UK are exposed to injured persons in an accident and emergency setting, particularly when they are ‘on call’, and attending patients who have suffered injury from a traumatic mechanism. Pre-Registration House Officers (PRHOs) in surgery, for example may be required to assess individuals who may be requiring surgical intervention following their traumatic injury. In most cases, these individuals will have been assessed by a ‘casualty’ senior house officer grade junior doctor, or a more senior member of the surgical team, but it is the PRHO who carries out the detailed ‘clerking’ of the patient. This process necessarily involves describing the wounds or injuries suffered. The house officer is of course privy to the descriptions used by their colleagues (which may of course be incorrect medico-legally, as the results of this survey indicate), and may follow their lead in the description of wounds or injuries noted. Any misdescription at this stage forms part of the permanent medical record, and the ‘clerking’ may contain the only full description of the injury pre-intervention, e.g., suturing or surgical exploration, etc. Anecdotal evidence amongst colleagues suggests that traumatic wounds and injuries are being misdescribed, and are not being photographed or otherwise documented at the time of admission, and not being subsequently ‘corrected’ further ‘downstream’. Debate in the medical press has previously raised the concern that injuries are being repeatedly mis-
described, particularly incisions as ‘lacerations’2 , and the decline in the teaching of medico-legal matters underpinning this inability of medical graduates to correctly identify wounds has been previously described in detail.1 The results of this small scale, single institution survey reinforce the key message that medical graduates in the UK are ill-equipped to interpret and describe wounds and injuries encountered in clinical practice, and having significant medico-legal importance. A larger national survey along the lines of this study could be undertaken, for example under the aegis of the Association of Forensic Physicians, and the results utilised to bring pressure on medical schools and post-graduate bodies to increase the teaching of clinical forensic medicine and in particular wounds and injuries in the modern curriculum and in continual professional development sessions. PowerPoint presentations could be effective at illustrating different wound types, their characteristics, and their medico-legal significance. In medical schools, case studies built around wound and injury types and patterns could form the basis of Problem Based Learning sessions during rotations in accident and emergency medicine. Society is becoming increasingly violent and litigious. Junior doctors are exposed to wounds and injuries, and from this survey, they are ill equipped to correctly identify common wounds. Inclusion of basic clinical forensic medicine in undergraduate medical curricula and postgraduate settings would go a long way towards encouraging junior doctors to have confidence in describing the injuries encountered on a daily basis, and prevent unnecessary heartache at a later date when they are called to account in court.
REFERENCES 1. Jones R. Undergraduate medicine’s legal wrangle. Student BMJ 2002; 10: 90–91. 2. Milroy CM, Rutty GN. If a wound is ‘neatly incised’ it is not a laceration. BMJ 1997; 315: 1312 (15 November). 3. WebPath – The University of Utah Internet Pathology Laboratory (http://medstat.med.utah/WebPath/). 4. PathGuy – www.pathguy.com/.
ORIGINAL COMMUNICATION
Wound and injury awareness amongst students and doctors R. Jones Department of Surgery, Queen Elizabeth Hospital, Woolwich, London, UK SUMMARY Introduction: Concern has been raised in the medical press regarding the inability of doctors to describe wounds and injuries of medico-legal significance correctly. Methods: Medical students and doctors of all grades, from the Department of Surgery at a London teachinghospital affiliated unit were shown a series of photographs illustrating wounds and injuries expected to be encountered in emergency medical practice. They were asked to identify the type of wound or injury as well as the manner in which that injury may have been caused. Result: The results indicated that students and doctors of all grades in this unit were not confident at identifying wounds and injuries, using the correct terminology. The term ‘laceration’ was widely used to describe incised wounds, and vice versa. Gun shot wounds were poorly identified as such, and were only correctly described by those who clearly ‘knew’ what they were looking at. Conclusion: In order to provide doctors with the skills with which they need to correctly describe wounds and injuries encountered in an emergency setting, this author proposes the introduction of specific teaching in wound identification at undergraduate and postgraduate levels. Ó 2003 Elsevier Ltd and AFP. All rights reserved. Journal of Clinical Forensic Medicine (2003) 10, 231–234
(PRHOs), Senior House Officers (SHOs), Registrars and Consultants in the Department of Surgery, Queen Elizabeth Hospital Woolwich between December 2002 and January 2003. The photographs were identified from WebPath3 and PathGuy4 – internet resources for general and forensic pathology. The research subject completed a structured questionnaire and the results analysed by the author. For each photograph, the subject was asked what type of wound/injury was illustrated, and how it might have been caused i.e., the mechanism of injury.
AIM To determine the level of awareness of a selection of wound types commonly encountered in clinical practice, and having medico-legal importance, amongst final year medical students and doctors working in a London teaching hospital setting.
METHODS A series of 6 photographs depicting wounds likely to be encountered in clinical practice (particularly in an emergency medicine/trauma setting) were shown to final year students, Pre Registration House Officers
RESULTS A total of 52 subjects took part in the study. There were 16 final year medical students, 10 PRHOs, 10 SHOs, 7 Registrars and 9 Consultants.
––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Dr. R. Jones MBBS, BSc.(Hons), Department of Surgery, Queen Elizabeth Hospital, Woolwich, 18 Speldhurst Road, Hackney, London E9 7EH, UK.
Photograph 1. Abrasion on an elbow Overall the cause of the wound was recognised by nearly 80%, but a large proportion of most grades
Correspondence to: Dr. R. Jones MBBS, BSc.(Hons). Tel.: +44-208986-8296. 231
232 Journal of Clinical Forensic Medicine Table 1 Responses by grade to photograph 1 (Abrasion) Type
Medical student PRHO SHO Registrar Consultant Total
Cause
Correct (%)
Incorrect (%)
Total
Correct (%)
Incorrect (%)
Total
13 (81) 5 (50) 5 (50) 7 (100) 7 (71) 37 (71)
3 (19) 5 (50) 5 (50) 0 2 (22) 15 (29)
16 10 10 7 9 52
12 (75) 7 (70) 7 (70) 7 (100) 8 (89) 41 (79)
4 (25) 3 (30) 3 (30) 0 1 (11) 11 (21)
16 10 10 7 9 52
could not ascribe the type of wound illustrated, and some incorrect terms used included a bruise and even a tangential bullet wound (Table 1). Photograph 2. A stab wound made by a single edged blade The incorrect use of terminology represented the biggest failure amongst all grades of respondents in this section – only 38% correctly identified the wound as a stab wound, most calling it a laceration. Causation was answered well – varying from 81 to 100% (90% overall) (Table 2). Photograph 3. Multiple lacerations of the hand (caused by a punch through heavy glazing) If ‘crush’ injury or ‘heavy machinery accident’ were excluded, this photograph was poorly identified by all grades of respondents. However, if these terms were
accepted, the following results were obtained; (see Table 3). Two thirds of respondents could correctly identify these injuries as involving some element of blunt trauma i.e., crush injuries, whilst the causation suggested by respondents universally involved heavy machinery or ‘mangling’ – few suggested any other form of blunt trauma, and none of the respondents suggested punching a hard object as a possible means of causation. The term laceration was used by 29% of respondents. Photograph 4. Close range (soft contact, low velocity) gun shot entry wound In general, this photograph elicited correct responses as to type and causation by those who ‘knew’ what they were looking at. Some respondents did not complete the ‘type of wound’ box for this photograph, but correctly identified the cause.
Table 2 Responses by grade to photograph 2 (Stab wound with single edged blade) Type
Medical student PRHO SHO Registrar Consultant Total
Cause
Correct (%)
Incorrect (%)
Total
Correct (%)
Incorrect (%)
Total
6 (38) 2 (20) 6 (60) 2 (29) 4 (44) 20 (38)
10 (62) 8 (80) 4 (40) 5 (71) 5 (66) 32 (62)
16 10 10 7 9 52
13 (81) 10 (100) 9 (90) 7 (100) 8 (89) 47 (90)
3 0 1 0 1 5
16 10 10 7 9 52
(19) (10) (11) (10)
Table 3 Responses by grade to photograph 3 (Multiple hand lacerations) Type
Medical student PRHO SHO Registrar Consultant Total
Cause
Correct (%)
Incorrect (%)
Total
Correct (%)
Incorrect (%)
Total
11 5 8 3 8 35
5 5 2 4 1 17
16 10 10 7 9 52
11 9 7 3 9 39
5 1 3 4 0 13
16 10 10 7 9 52
(67) (50) (80) (43) (89) (67)
(33) (50) (20) (57) (11) (33)
(67) (90) (70) (43) (100) (75)
(33) (10) (30) (57) (25)
Wound and injury awareness 233 Table 4 Responses by grade to photograph 4 (close range gunshot entrance wound) Type
Medical student PRHO SHO Registrar Consultant Total
Cause
Correct (%)
Incorrect (%)
Total
Correct (%)
Incorrect (%)
Total
4 (25) 5 (50) 7 (70) 5 (71) 7 (78) 28 (54)
12 (75) 5 (50) 3 (30) 2 (29) 2 (22) 24 (46)
16 10 10 7 9 52
5 (31) 6 (60) 7 (70) 5 (71) 7 (78) 30 (58)
11 (69) 4 (40) 3 (30) 2 (29) 2 (22) 22 (42)
16 10 10 7 9 52
Incorrect responses varied from ‘cigarette burn’, to melanoma, whilst one respondent thought this wound was an insect bite (Table 4).
(or deliberate self-harm). None suggested the term ‘defensive wounds’ (Table 5). Photograph 6. Hard Contact (low velocity) gunshot entrance wound with stellate skin splitting at the wound edges
Photograph 5. Incised (defensive) wounds on forearm The use of the term laceration predominated, and was followed by a correct response to causation by the majority of respondents – i.e., sharp force trauma. Many suggested that the wounds were self-inflicted
As with photograph 4 of the close range gunshot entrance wound, respondents correctly identifying the type of wound also identified the mechanism of
Table 5 Responses by grade to photograph 5 (Incised wounds on forearm (defensive wounds)) Type
Medical student PRHO SHO Registrar Consultant Total
Cause
Correct (%)
Incorrect (%)
Total
Correct (%)
Incorrect (%)
Total
5 (31) 1 (10) 2 (20) 1 (14) 1 (11) 10 (19)
11 (69) 9 (90) 8 (80) 6 (86) 8 (89) 42 (81)
16 10 10 7 9 52
13 (81) 10 (100) 9 (90) 5 (71) 9 (100) 46 (88)
3 0 1 2 0 6
16 10 10 7 9 52
(19) (10) (29) (12)
Table 6 Responses by grade to photograph 6 (Hard contact gunshot entrance wound) Type
Medical student PRHO SHO Registrar Consultant Total
Cause
Correct (%)
Incorrect (%)
Total
Correct (%)
Incorrect (%)
Total
6 (38) 3 (30) 1 (10) 1 (14) 4 (44) 15 (29)
10 (62) 7 (70) 9 (90) 6 (86) 5 (56) 37 (71)
16 10 10 7 9 52
6 (38) 3 (30) 1 (10) 1 (14) 4 (44) 15 (29)
10 (62) 7 (70) 9 (90) 6 (86) 5 (56) 37 (71)
16 10 10 7 9 52
Table 7 Summary table of responses by grade for all photographs Wound type
Abrasion Stab wound Multiple lacerations Close range gunshot entrance wound Incised wounds (defensive) Contact gunshot entrance wound
Type
Cause
Correct (%)
Incorrect (%)
Correct (%)
Incorrect (%)
71 38 67 54 19 29
29 62 33 46 81 71
79 90 75 58 88 29
21 10 25 42 12 71
234 Journal of Clinical Forensic Medicine wounding correctly, and ‘knew’ what they were looking at. For the majority, this photograph caused the most difficulty of them all (Table 6). Incorrect terms included, ‘abscess’, ‘burn’, ‘pyoderma gangrenosum’ and ‘blunt trauma’. Table 7 illustrates a summary of all responses by wound type and grade.
DISCUSSION The ability to recognise and interpret wounds and injuries is an important skill that should be within the capabilities of all practicing medical graduates. Even the most junior doctors in the UK are exposed to injured persons in an accident and emergency setting, particularly when they are ‘on call’, and attending patients who have suffered injury from a traumatic mechanism. Pre-Registration House Officers (PRHOs) in surgery, for example may be required to assess individuals who may be requiring surgical intervention following their traumatic injury. In most cases, these individuals will have been assessed by a ‘casualty’ senior house officer grade junior doctor, or a more senior member of the surgical team, but it is the PRHO who carries out the detailed ‘clerking’ of the patient. This process necessarily involves describing the wounds or injuries suffered. The house officer is of course privy to the descriptions used by their colleagues (which may of course be incorrect medico-legally, as the results of this survey indicate), and may follow their lead in the description of wounds or injuries noted. Any misdescription at this stage forms part of the permanent medical record, and the ‘clerking’ may contain the only full description of the injury pre-intervention, e.g., suturing or surgical exploration, etc. Anecdotal evidence amongst colleagues suggests that traumatic wounds and injuries are being misdescribed, and are not being photographed or otherwise documented at the time of admission, and not being subsequently ‘corrected’ further ‘downstream’. Debate in the medical press has previously raised the concern that injuries are being repeatedly mis-
described, particularly incisions as ‘lacerations’2 , and the decline in the teaching of medico-legal matters underpinning this inability of medical graduates to correctly identify wounds has been previously described in detail.1 The results of this small scale, single institution survey reinforce the key message that medical graduates in the UK are ill-equipped to interpret and describe wounds and injuries encountered in clinical practice, and having significant medico-legal importance. A larger national survey along the lines of this study could be undertaken, for example under the aegis of the Association of Forensic Physicians, and the results utilised to bring pressure on medical schools and post-graduate bodies to increase the teaching of clinical forensic medicine and in particular wounds and injuries in the modern curriculum and in continual professional development sessions. PowerPoint presentations could be effective at illustrating different wound types, their characteristics, and their medico-legal significance. In medical schools, case studies built around wound and injury types and patterns could form the basis of Problem Based Learning sessions during rotations in accident and emergency medicine. Society is becoming increasingly violent and litigious. Junior doctors are exposed to wounds and injuries, and from this survey, they are ill equipped to correctly identify common wounds. Inclusion of basic clinical forensic medicine in undergraduate medical curricula and postgraduate settings would go a long way towards encouraging junior doctors to have confidence in describing the injuries encountered on a daily basis, and prevent unnecessary heartache at a later date when they are called to account in court.
REFERENCES 1. Jones R. Undergraduate medicine’s legal wrangle. Student BMJ 2002; 10: 90–91. 2. Milroy CM, Rutty GN. If a wound is ‘neatly incised’ it is not a laceration. BMJ 1997; 315: 1312 (15 November). 3. WebPath – The University of Utah Internet Pathology Laboratory (http://medstat.med.utah/WebPath/). 4. PathGuy – www.pathguy.com/.