An Introduction to Forensic Imaging
Nancy S. Adams, BSRS, RT(R)
*Clinical Coordinator, Radiologic Sciences, Itawamba Community College, Fulton, Mississippi.
Address correspondence to: Nancy S. Adams, BSRS, RT(R), Clinical Coordinator, Radiologic Sciences, Itawamba Community College, 602 West Hill Street, Fulton, MS 38843. E-mail: firstname.lastname@example.org.
Disclosure: Ms Adams reports serving on the speakers' bureau for Medical Technology Management Institute.
Radiography is commonly used in the collection of forensic evidence and is especially useful for confirming the identity of both living and deceased subjects, identifying pre-existing skeletal trauma, assisting in the determination and/or confirmation of cause of death, and locating hidden foreign bodies, such as fragments of explosives and packages of illegal substances. In these instances, radiographers need to understand the appropriate forensic imaging protocols for each situation, as well as the legal and ethical issues involved. The following article discusses these important aspects of forensic imaging, as well as new developments in technology, in an effort to provide the radiographer with the necessary tools to function as part of the forensic team.
Radiography is one of the most commonly used methodologies in the collection of forensic evidence and is especially useful for confirming the identity of both living and deceased subjects; identifying pre-existing skeletal trauma (eg, in cases of suspected non-accidental injuries); assisting in the determination and/or confirmation of cause of death; and locating hidden foreign bodies, such as fragments of explosives and packages of illegal substances. Because radiographers are frequently asked to image both living and deceased subjects in order to obtain evidence relevant to identification, cause of death, and/or criminal activity, a knowledge and understanding of the legal and ethical issues, as well as appropriate forensic imaging protocols is of the utmost importance.1
History of Forensics
The world of forensics has only recently captured the attention of the general public, largely due to works of fiction and television programs. These programs have enjoyed great popularity and focused world attention on today's issues, but one has to remember that these are fictional situations designed to attract an audience, and many times offer inaccurate or misleading information. What most people do not realize is that components of forensic sciences as we know them today actually existed several thousand years before the birth of Christ. For instance, the ancient Babylonians recognized the distinctive characteristics of fingerprints and used fingerprints on clay tablets for business transactions. Thumbprints have also been found on clay seals in ancient China. In Egypt, Pharaoh Zoser, the first pharaoh of the third dynasty, appointed a chief justice physician to investigate questionable deaths. The earliest record of a murder trial was found in Mesopotamia inscribed on a clay tablet dating back around 1850 BC, and the Hammurabi Code, possibly the oldest written code of law, was inscribed in stone around 2000 BC.
The Greco-Roman era provided us with the foundations of modern medicine based on the scientific methods and philosophy of Hippocrates. They also had an extensive knowledge of pharmacopeia. Many poisons, such as arsenic, mercury, belladonna, hemlock, and opium, contributed to any number of murders and suicides during this time. Using scientific reasoning, a Roman physician, Antistius, examined the corpse of Julius Caesar after his assassination in 44 BC. He counted 23 wounds and announced that only 1 stab wound to the chest was fatal. In another case, an attorney in the Roman courts, Quintilian, proved that bloody handprints found at the scene of a crime were meant to frame a blind man of his mother's murder.
The Chinese also contributed to our understanding of forensic medicine and investigation. Written in 1247, a Chinese book, whose title is translated as "Instruction to Coroners," is recognized as the oldest existing book on forensic or legal medicine in any civilization, and it details procedures to follow in the investigation of suspicious deaths.2
Ancient civilizations also furthered our understanding of human anatomy. For instance, Ancient Egyptians and Babylonians possessed considerable knowledge of human anatomy, probably due to the practice of embalming, which was forbidden for many other nations because of religious and social prejudices against dissection of the dead. In India, a way was found to study anatomy by placing the deceased in baskets floating in rivers and observing the anatomical structures as the body decomposed. Throughout history, scientists as well as artists studied human anatomy via dissection by either purchasing or stealing corpses. Regardless of the method of study, each made valuable contributions to the knowledge of human anatomy, in turn contributing to modern forensic science.
Origins of the Medico-Legal System and Terminology
Today's system of coroners and medical examiners can be traced back to 1192, when Richard the Lion-Hearted was kidnapped by Leopold of Austria and held for ransom. Because the English treasury did not have sufficient funds to meet the ransom demand, a plan was devised to use corpses as a source of revenue. The title of "Coroner" was given to each knight who took possession of a deceased felon's property, enriching the royal treasury. This title comes from the Latin "custom placitorum coronae," or "supervisor of the Crown's pleas." This system of laymen coroners traveled from England to the British colonies, and in 1883, the Medico-Legal Society of New York was founded, marking the beginning of a new investigative system. Today, a distinction is made between the medical examiner and the coroner. Under the medical examiner system, the head of the department is a board-certified forensic pathologist who usually is responsible for directing and appointing the personnel of the department. The coroner is typically an elected official who does not necessarily need to be medically trained.2 Both the medical examiner and coroner systems exist today throughout America as the primary form of medico-legal investigations. Twenty-one states employ the medical examiner system, 11 have the coroner system, and 18 states have a mixed system. National trends indicate an increasing number of states are adopting the medical examiner system.3
The term "forensic" is derived from the Latin forens(is): of or belonging to the public, or forum, and by extension also meaning argumentative, rhetorical, belonging to debate or discussion. Today, forensics may be defined as pertaining to, or connected with, or used in courts of law or public discussion and debate; therefore, the forensic sciences are defined as the application of specialized scientific and/or technical knowledge to questions of civil and criminal law, primarily in court proceedings. Forensic radiology may be defined as the performance, interpretation, and reportage of radiologic examinations and procedures that have to do with the courts and/or the law. Although one of the most commonly used methods of accumulating forensic evidence in both determination of cause of death and identification of victims, radiology is not yet recognized as a formal forensic science.4 The following sections discuss those disciplines formally recognized by the forensic community.
Formally Recognized Forensic Disciplines
Toxicology involves the examination of body fluids or tissues for the presence and quantity of substances, such as drugs or poisons in ante- or postmortem casework. Examples include body fluids, such as blood, urine, and spinal fluid, and organ and muscle tissue.
Firearms identification determines whether an evidence bullet was fired from a suspect weapon. It may also include comparison of fired cartridge cases, firearm function tests, serial number restorations, and distance determinations. Toolmarks left at a crime scene or on a victim by various types of implements (eg, knives, screwdrivers, or pliers) can be microscopically compared to test marks made in the laboratory by suspect tools. The forensic scientist is then able to determine whether a suspect tool was used in the commission of a crime.
A questioned document contains a signature, handwriting, typewriting, or other mark whose source or authenticity is in dispute or doubtful. The forensic document examiner makes examinations, comparisons, and analyses of documents to establish genuineness, expose forgery, or reveal alterations. Letters, checks, driver licenses, contracts, wills, voter registrations, passports, petitions, threatening letters, suicide notes, and lottery tickets are common types of questioned documents.
Trace evidence is physical evidence that results from the physical transfer of small or minute quantities of materials (eg, hair, textile fibers, paint chips, or glass fragments). This category of evidence encompasses many diverse types of microscopic materials, as well as some examples that are easily visible to the naked eye.
In the discipline of controlled substance identification, evidence is examined to identify drugs—either prescription drugs, such as Valium, or illegal drugs, such as cocaine. Evidence examples might include plant material, powder, drug paraphernalia, tablets, and pills.
This discipline encompasses a variety of tests to determine the presence of blood, semen, saliva, or other body fluids. Chemical and microscopic methods of testing are often used to determine whether samples are suitable for subsequent DNA testing.
Fire Debris/Arson Analysis
Arson analyses include the examination and testing of items and debris collected from a fire scene. The scientist tests materials to determine whether an ignitable material is or was present, which can help investigators determine whether a fire was deliberately set.
Impression evidence involves objects or materials that have retained the characteristics of other objects that have been physically pressed against them (eg, fingerprints or shoe/tire prints). A latent print is an impression that is not readily visible, made by contact of bare hands or feet with a surface resulting in the transfer of materials from the skin to that surface. Footwear or tire track impressions from a crime scene can be found on many types of material, such as hard flooring, dirt, mud, and dust.
Blood Pattern Analysis
Blood pattern is the analysis of stains left by blood shed at a crime scene. Bloodstain patterns can yield valuable information for the reconstruction of the incident. Bloodstain pattern analysis may clearly define the location of the victim or the assailant(s) by establishing their actions.
Crime Scene Investigation
Crime scene investigation involves the recovery and analysis of forensic evidence, in addition to addressing issues such as security, prevention of contamination, locating and collecting items of evidence, interpretation of evidence, and possible reconstruction of the event. Crime scene investigation provides the best opportunity to determine actual events associated with the commission of a crime.
Medico-Legal Death Investigation
The medical examiner community is a unique group of professionals who play an important role in the investigation of sudden, unnatural, unexplained, or suspicious deaths, including homicides, suicides, unintentional injuries, drug-related deaths, and other deaths that are sudden or unexpected, by determining the cause and manner of death. In many jurisdictions, responsibility for conducting death investigations may rest with pathologists, medical examiners, or coroners.
The discipline of digital evidence includes all facets of crime where evidence may be found in a digital form. It includes forensic imaging, forensic audio and video analysis, and analyzing computer files and other digital data from computer systems.3
Early Use of Imaging in Forensics
From the beginning with Professor Wilhelm Roentgen's announcement to the world of his discovery of "a new kind of ray" in December 1895, its potential application to both the field of medicine and forensic investigations was immediately recognized. Scientists around the world had been conducting similar experiments and were able to reproduce Roentgen's findings with very little effort. The usefulness of the X ray as a noninvasive tool to both people and objects was self-evident. Within months, X rays were being used to assess broken bones, locate bullets, and resolve court cases.
It is thought that the first X ray made in the United States was by Professor A. W. Wright of Yale University in February 1896. It is probably the first forensic radiograph because it determined the cause of death. A rabbit purchased at the local market was the subject. After an exposure of 1 hour, the image revealed buckshot. The manner of the rabbit's death had not been previously known. The buckshot was extracted. Case closed.
The first court case in North America involving X rays occurred in Montreal, Canada. One gentleman shot another in the lower leg on Christmas Eve 1895. The physician was unable to extract the bullet by probing, and the wound healed. X rays were later used to locate the bullet in the healed extremity, and it was removed. The X ray plate was used in court, and the gentleman was convicted of attempted murder.
Roughly 1 year later in December 1896, the first civil case in the United States in which X rays were accepted into evidence involved a malpractice suit. The physician had misdiagnosed a hip fracture, which led to disability and a shortening of the affected limb. Although hotly debated, the judge ruled in favor of allowing the images as evidence.
The first year following Roentgen's discovery also saw the first court case involving radiation burns. X rays of an ankle injury using exposure times of 35 to 40 minutes with the tube only 6 inches from the skin resulted in such severe radiation damage that the foot and ankle had to be amputated. The jury awarded the plaintiff $10 000 in damages.
In addition to the application of Roentgen's discovery to humans, other uses were quickly recognized—among them, using X rays to investigate suspicious packages and examine luggage and packages in customs houses. The process of applying powdered lead tetroxide to fingers and exposing the tips to soft X rays to evaluate fingerprints, development of bone age comparisons, and dental X rays were all undergoing consideration and investigation in 1896. During this same time span, X rays were being used to examine mummies, detect fake jewels, and determine authenticity of artwork. Professor Roentgen's discovery in that darkened laboratory in 1895 laid the foundation for a medical and investigative tool with a potential that was quickly recognized, and continues to develop, grow, and evolve at a mind-boggling pace.4
Forensic Imaging Today
Today, most forensic imaging is not performed in the hospital environment, but in a morgue facility (Figure 1), and conventional diagnostic X-ray equipment is the most commonly used imaging equipment in forensic settings. There is no standardization between facilities or states, and often budgets for imaging equipment and maintenance are almost nonexistent. Many times, autopsies are carried out in funeral homes where equipment is not available. Approximately 50% of the population of this country is served by systems with forensic pathologists. In most states, medico-legal death investigations are conducted by county offices that often cannot directly support complete death investigations. Although many medico-legal offices are of high quality, others lack funding, competent staff, and facilities.3 Dependent on the size and resources available to a facility, the X-ray equipment runs the gamut from a mobile unit, to a C-arm, to a fixed radiographic unit, to computed tomography (CT) scanners. Image processing is usually a conventional darkroom, quite possibly a tabletop unit. A limited number of facilities have been able to purchase computed radiography (CR) equipment (Figure 2), and a mobile CR/digital radiography (DR) unit is almost unheard of, although this type of imaging system would be very cost effective. The mobile CR/DR unit does not require much floor space; stores images electronically; eliminates the need for a darkroom, chemicals, film storage, and processor maintenance; may be used with a portable protective barrier and lead aprons, eliminating expensive lead lining for walls; and can be used in the autopsy room for immediate viewing by the pathologist.
Because most medical examiner facilities today do not have access to state-of-the-art equipment or a full-time radiographer, oftentimes the imaging is performed by a morgue assistant or perhaps another employee of the facility. Unfortunately, these individuals have not received adequate training, and as a result, image quality is poor. Although the American Society of Radiologic Technologists (http://www.asrt.org/), the International Association of Forensic Radiographers (http://www.afr.org.uk/), and the very few forensic radiographers and radiologists who are members of the American Academy of Forensic Sciences (http://www.aafs.org/) are taking steps to focus attention on the need for qualified radiographers and develop a forensic curriculum, a change such as this will take time. In the meantime, some radiographers and radiography programs are "stepping up to the plate" by forming relationships with medical examiner facilities and arranging for students to visit morgues, observe autopsies, and perform forensic imaging (Figure 3). Individual radiographers who are seriously interested in performing forensic imaging are either taking call as needed or donating their own time to assist the facility by improving the quality of their images. These arrangements are proving to be a beneficial partnership because the students and radiographers gain valuable experience while updating and maintaining the equipment, developing exposure charts and techniques for the facility, and providing the staff with training.
One group of students has already been able to improve overall image quality for a facility by cleaning the cassettes and intensifying screens, recognizing processing problems and establishing preventive maintenance on the processor, and cleaning and repairing the illuminators (Figures 4 and 5). They have tested the screens and made sure that the ones in use have no artifacts and are all the same speed. In addition, they have been able to locate items such as stationary grids, additional cassettes, and even cardboard cassettes that are no longer being used in CR/DR departments and get them donated. A technique guide adapted to the facility and prepared for ease of understanding by the untrained personnel has been developed and is in use (Figure 6). The students have donated film markers for use at the facility and have demonstrated to the personnel the proper use of the X-ray equipment and its flexibility and limitations in obtaining images. At this particular site, the students have been able to assist with testing of a new portable X-ray unit with military implications (Figure 7) and work on techniques with the cardboard cassette for the anthropologist to use on skeletonized remains (Figure 8). One bonus to having students participating in forensic imaging: it gives them an opportunity to "think outside the box" and apply critical thinking skills because they have to devise alternative methods to overcome problems, such as rigor mortis or advanced decomposition. It also gives students insight to the true world of forensics and helps them determine whether it is a career path they would like to pursue.
Safety in Forensic Radiology
Regardless of the type or age of the imaging equipment, it should be maintained and inspected on a regular basis and adhere to the same state Bureau of Radiological Health regulations as any other installation of ionizing radiation equipment. All personnel who work in the radiation area should wear personnel monitoring devices and maintain dosimetry reports. If a mobile unit or C-arm is being used, the direction of the primary beam is an important consideration: perhaps the unit should be directed toward one wall with a thickness that may allow it to be designated as a primary barrier.
The 3 cardinal principles of radiation safety must be followed: (1) time; (2) distance; and (3) shielding. Distance is probably the most important factor to consider. The minimum distance is at least 6 feet from the source, and all personnel present must be properly shielded with lead aprons and/or portable lead barriers. Regarding time, the shortest exposure time should always be used for static imaging, and if fluoroscopy is utilized, then intermittent exposure and a cumulative time of less than 5 minutes should be the rule.
In addition to radiation safety, personnel must adhere to universal precautions and wear personal protective equipment whenever the possibility of coming into contact with any type of body fluids exists (Figure 9). In the morgue, this should be assumed all the time, and some requirements, such as shoe covers, may be more important in the morgue environment. Image receptors or cassettes should always be placed in plastic covers during imaging procedures and wiped down with antiseptic wipes or solutions after use. Personnel should have all vaccinations completed and up-to-date, including hepatitis and tetanus. In other words, all safety regulations required in the hospital environment also should apply to the morgue, and strict enforcement should be maintained. Policies and procedures regarding safety and health in the imaging section of the morgue should be published as part of the facility's protocols.
Legal and Ethical Considerations
All medical imaging personnel should be thoroughly familiar with the Health Information Portability and Accountability Act (HIPAA). This act ensures that all patient information is held in strictest confidence, and anyone found to be in violation of HIPAA may be subject to severe disciplinary actions. The same degree of confidentiality applies to anyone involved in imaging in a morgue facility. Forensic cases should always be regarded as sub judice. In law, sub judice, which is Latin for "under judgment," means that a particular case or matter is currently under trial or being considered by a judge or court, and should never be discussed with any person not directly involved in the case until the inquest or investigation has been completed. If the case is being considered by a court of law, the principles of confidentiality will be applicable throughout the proceedings. The radiographer should abide by the American Registry of Radiologic Technologists Code of Ethics when imaging the deceased just as he or she would for the living.4
Collection and Preservation of Evidence
Although the radiographer may not be directly involved in the collection and preservation of evidence, he or she needs to be familiar with certain procedures. When imaging an individual in the emergency department who may be associated with a possible crime, it is important to preserve any artifacts that could become evidence. For example, if clothing has to be removed by cutting, never cut through a perforation that could be from a bullet or stab wound. It is also important to never throw away any articles of clothing. Everything should be placed in paper bags rather than plastic. If hands have been bagged, do not remove the bags because this is done to preserve evidence, usually for gunshot residue and underneath fingernails. Never hesitate to ask questions before removing anything that might be related to the incident, and always make sure all artifacts remain with the law enforcement personnel accompanying the individual.
When imaging the deceased in the morgue, the same protocols apply. It is advisable to make sure that the deceased has been photographed, with all personal effects in place, prior to performing radiographic images. In some facilities, it is protocol to leave all jewelry on to protect employees from being accused of theft. If an item should be removed to improve image quality, make sure photographs have been taken, and document it in the record. The item should at all times remain with the evidence collection. The radiographer must remember that chain of custody of evidence must be maintained and documented at every step or it may become inadmissible in court.1
Using Medical Imaging in Forensic Science
The following are examples of when imaging is of value in a forensic investigation. These examples include, but may not be limited to:
- Investigation of non-fatal injuries. Examples include non-accidental trauma, such as abuse of children and vulnerable adults, motor vehicle accidents, assault, medical negligence, compensation claims, industry-related disease or injury, and torture or human rights abuses.
- Location of forensic evidence. Usually to demonstrate the presence of foreign objects within the body, and may include drug smuggling, ingested materials such as unmounted jewels, ballistic material such as bullets, or non-ballistic material such as needles or knife blades.
- Cause of death. To produce evidence in support of suspicious or unexplained death investigations. Examples include motor vehicle accidents, homicide, suicide, death following medical intervention, custodial death, discovery of decomposed remains, mass fatalities, genocide, and sudden infant death.
- Human identification. To produce evidence to help confirm, determine, or eliminate the identity of both living and deceased persons. Examples include demonstration of dental structures for comparison purposes; demonstration of other anatomical structures, trauma, or pathological conditions for comparison purposes; to determine biological profile (eg, age, sex, and stature) via evaluation of skeletal structures; 3-dimensional (3D) multiplanar reconstruction, such as facial reconstruction; and demonstration of personal effects, such as jewelry.1
When imaging the living, radiographers need to be aware that any examination they perform could potentially be forensic in nature; therefore, the radiographer must comply with the codes of professional conduct and regulations governing the safe and efficient application of ionizing and nonionizing radiation. When undertaking forensic examinations of live individuals, the radiographer must be aware of and comply with local protocols addressing issues such as authorized referrers, consent, confidentiality, continuity of evidence, and clinical protocols for specific examinations for non-accidental trauma. Particularly in suspected child abuse, the radiographer must take every measure to produce images providing the best possible recorded detail, because prior injuries may be very subtle and difficult to detect. Artifacts that may be produced by clothing or diapers need to be prevented, and of course, correct and visible image marking within the collimated light field is required, as well as accurate patient identification. Any error in these requirements may result in the images being disqualified as evidence.1
When imaging the deceased individual and/or pathological specimens, the radiographer must abide by all the relevant codes of conduct and regulations governing radiation that were previously discussed. In addition to the above noted protocols, the radiographer must also be aware of and comply with protocols addressing issues such as cultural and religious sensitivities, privacy and dignity, and cadaver and specimen transfers. The radiographer should remember that all examinations of the deceased are also forensic examinations sub judice. In addition to normal clinical referrers, requests may be made by recognized, approved referral sources, such as the forensic pathologist, odontologist, anthropologist, physician, and law enforcement officials.1
Because radiographic imaging plays a vital role in determining both cause of death and identification, the radiographer should make every effort to produce images as close to true anteroposterior (AP)/posteroanterior (PA) and lateral projections as possible, recognizing that the postmortem images may need to be compared to antemortem images at some point. If remains are fragmented or skeletonized, digits should be imaged in a PA projection to allow for bone age evaluation. The skull should be imaged in true AP and lateral projections because the frontal sinuses and the sella turcica can provide unique markers in identification. If imaging an entire body for identification purposes, ensure that every joint is included because orthopedic appliances or unique degenerative changes aid the identification process. The thoracic and abdominal cavities may reveal everything from pacemakers to stents to arthritic changes in the vertebral column. Sharp recorded detail in the postmortem image is important because bony trebeculae may be a significant marker if a comparative analysis is to be performed. Again, the importance of correct anatomical markers within the collimated light field is critical.
The radiographer must remember that the remains of a deceased individual may be found in every conceivable condition, from early soft tissue stages to advanced skeletonization (Figures 10 [*WARNING: Very Graphic Image*] and 11). As a result, technical factors may have to vary greatly from subject to subject. It is imperative that the radiographer has a thorough understanding of the factors governing image formation—both visibility and sharpness of details. In the early soft tissue stages, techniques may be comparable to those used on living subjects, but as decomposition increases, loss of tissue and increase in gas formation will impact technique. If the remains are very fragmented, or skeletonized, systems that provide wide exposure latitude and sharp image detail should be considered. Ideally, CR/DR systems meet these requirements, but in instances where this type of equipment is not available, every effort should be taken to utilize factors to improve image quality, including increased source image receptor distance, small focal spot, close collimation, optimal kilovolt peak (kVp), and sufficient milliampere seconds (mAs) to make detail visible. The radiographer should remember that kVp controls penetration and scale of contrast. mAs controls density. As a standard rule, if the structure being radiographed is outlined in the image, then kVp is optimal and adjustments should be made in mAs.
Whether the individual is living or deceased, the radiographer always performs a technical evaluation of the images taken. This includes ensuring proper image sharpness and visibility are obtained, the structure under evaluation is positioned correctly, image markers are visible and correct, and image identification is accurate and visible. Although the radiographer does not interpret images, he or she critiques images for positional and technical accuracy, and is adept at recognizing anatomical and positional variances that may ultimately lead to exceptional skills for comparing ante- and postmortem images. The radiographer is also able to reproduce images that accurately mimic antemortem images for comparison purposes.
Imaging in Mass Fatality Events
In mass fatality events, the radiographer is usually going to be a member of a formal forensics team, rather than the individual in an emergency department or morgue. In these events, the number of casualties exceeds the ability of the local or regional authorities to handle the event, and the assistance of an organized response is required. Regardless of the type of situation, many similarities exist in performing forensic radiographs. These include:
- Obtaining images as close as possible to antemortem imaging in AP/PA and lateral projections;
- Providing optimal recorded detail and ensuring proper visibility of the structures;
- Making sure the image markers are correct and visible;
- Adhering to radiation safety protocols; and
- Abiding by all relevant confidentiality and ethical standards.
A noticeable difference that might occur in this type of event is not so much determining the cause of death, but identifying the deceased individual. In these instances, the body may be badly burned or fragmented (Figures 12 and 13), and therefore, appropriate technical factors become even more critical to obtaining images with proper sharpness as well as contrast and density. Whole-body imaging, rather than selective part imaging, may be required. Examples may be an airplane crash versus a hurricane. In the plane crash, the bodies will probably be very fragmented and possibly burned. In the aftermath of a hurricane, the bodies are usually intact. This would require AP imaging of the skull, thorax, abdomen, pelvis, upper and lower extremities ensuring all joints are visualized, and probably a lateral skull projection. If some type of explosive device is suspected of causing the event, then X ray is going to be used in a different fashion—scanning the remains "as is" in some type of container searching for unexploded ordinance, shrapnel, personal effects, and anything else that could cause possible harm to the members of the morgue team. If biologic or radiologic hazards are suspected, then decontamination teams must be utilized first.5
Working conditions for the radiographer will vary widely depending on the size, location, and type of event (Figures 14-16). The operations may be carried out in a medical examiner's facility or in a portable morgue. The radiographer must be prepared to work under extreme environmental conditions. Following Hurricane Katrina, the devastated area was so vast and total that no amenities existed, and the response teams worked and lived under very primitive conditions. Following other types of mass fatality events, the teams might have access to hotels and restaurants to provide adequate living conditions. The radiographer also must be prepared to work with any type of X-ray equipment, ranging from a second-hand, old piece of equipment in a rundown morgue, to a portable unit, to a C-arm, to mobile CR equipment, and possibly CT scanners. Each event, as well as the working conditions, will be very different from preceding events. This means the radiographer who participates in a mass disaster must be able to adapt quickly and be very innovative.
Beside primitive living conditions in mass disasters, the radiographer must also be prepared for the emotional impact that encountering possibly hundreds of deceased individuals, ranging from the very elderly to the very young, will have on team members. This is an aspect of mass disaster response that one has to accept, determine whether this is something he or she can deal with, and then move forward. Disaster response teams usually have chaplains and mental health personnel, as well as medical teams, as members or concurrently deployed and available to team members. Perhaps the best medicine, however, is the support of fellow team members and a sense of humor.
Current Developments in Forensic Radiography
Due to several catastrophic events over the last decade, including the Oklahoma City bombings, 911, the London bombings, tsunamis, and hurricanes, quick response to identify victims is demanded by the public, and forensics teams, especially in the United States and Great Britain, have evolved into organized rapid response teams with mobile deployable morgues for use if needed. X ray has become an increasingly important component for several reasons:
- It is noninvasive;
- CR/DR has changed the face of radiology because it is fast, can be digitally stored, does not require chemicals or hard copy film, and can be electronically transmitted; and
- The units can be hardened and are much more compact and mobile.
Although the global birthrate has dropped, the population continues to grow, and it is estimated that by 2050 it will exceed 9 billion.6 However, there has not been a decline in catastrophic events—either manmade or naturally occurring. As a result, more people will be in the path of these events, and many religions have very strong beliefs forbidding invasive autopsies. Radiography is rapidly gaining attention in the forensic world because it is noninvasive, and with 3D imaging, it is becoming the preferred tool in many instances due to its unique capabilities. Today, CT is being coupled with software to perform virtual autopsies. Although still considered to be in research stages, virtual autopsies are being used more and more around the world. Mobile CT units have been taken into the field and utilized for autopsies, using 3D imaging. 3D imaging has proven successful in demonstrating to a jury the path of bullets, in cases where autopsy photographs were hard to understand and very disturbing. Magnetic resonance imaging has also been used to obtain 3D images to use with virtual autopsy. Even ultrasound is being used with certain applications. And as radiology equipment continues to evolve and more applications are discovered for its use in the field of forensics, so will the role of the radiographer. Today, programs of study are being developed that will address the educational opportunities for radiographers interested in pursuing a career in forensics.
Ensuring Images Are Admissible
Regardless of the type of equipment being utilized or the environmental conditions the radiographer encounters, he or she must always remember that before any imaging or imaging report can be accepted for use in a court of law, it must be judged to be admissible as evidence. To be admissible, the evidence must be properly authenticated and continuity of evidence must be demonstrated. The radiographer, supported by an appropriate witness, should be able to attest in a court of law that any specific image was produced by him or her at the date and time indicated and that the image is of the identified evidence, individual, or body part and has not been tampered with during, or as a result of, the image production process. The radiographer must ensure that all data and identifiers are recorded on the images, including date, time, and location. And always ensure that anatomical markers are correct and clearly visible within the collimated light field. If any data or markers are not visible or correct, the image should be repeated.1
In closing, this article provides an overview of the main aspects of forensic imaging, including the appropriate forensic imaging protocols and the legal and ethical issues that radiographers need to be aware of. However, there is much more to forensic imaging, and the radiographer should remember that when working in forensics, the deceased individuals once loved, laughed, danced, had dreams, and are deserving of our care and respect, similar to any living individual. Most importantly, we must remember that when we do our jobs correctly, we may bring peace to a loved one.
1. Guidance for Radiographers providing Forensic Radiography Services. London, UK: The Society and College of Radiographers and The Association of Forensic Radiographers; 2005.
2. Laudicina P. Forensic Milestones: Historic Overview. Unpublished compilation.
3. Status and Needs of Forensic Science Service Providers: A Report to Congress. 2004. Available at: http://www.ncjrs.gov/pdffiles1/nij/213420.pdf. Accessed March 9, 2009.
4. Brogdon BG. Forensic Radiology. Boca Raton, FL: CRC Press LLC; 1998.
5. Disaster Mortuary Operational Response Team Standard Operating Procedures. 2008. Available at: http://www.dmort7.org/downloads/DMORT_SOP_2008jn2.pdf. Accessed March 9, 2009.
6. International Database-World Population. US Census Bureau Web site. Available at: http://www.census.gov/ipc/www/idb/worldpopgraph.html. Accessed March 9, 2009.
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An Introduction to Forensic Imaging
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