1. Radiographing Prison Inmates and Forensic Radiology 7 18 2012

2. Radiographing Prison Inmates Base on article by Linda Rarey, MA, CNMT, R.T. (R)(N) Radiology Technology magazine May/June 2011

3. US has highest incarnation rate in world (2008) 754 inmates per 100,000 US residents Or approximately 2.2 million total (includes Federal, State, City, & County) Thousands will be brought to medical facilities to be treated for diseases and injuries

4. Prison vs. Jail One year or less generally stay in City or County: jail (may have own basic medical units) Longer sentences go to state or federal: prison (may have huge medical facilities available)

5. Prisoners have many medical issues Hepatitis B &C AIDS and HIV Tuberculosis Dementia (2X rate regular population- may eventually require 24 hr care) Substance abuse Medication/pharmacy needs Skin problems- lice, scabies Cirrhosis Women must receive mammograms after age 40

6. “Maximum Security Nursing Home” Most prisoners considered to have health of someone 10 yrs older than non-incarcerated person due life style and poor previous health care Inmates over 50 are considered “older” By 2025 estimated over half of prison population will be over 55 yrs old

7. Conditions warranting transfer to outside hospital facility Cardiac arrhythmia or suspected heart attack Severe hypertension or shock Respiratory conditions requiring blood gas monitoring (severe asthma or need intubation 2-3 epileptic seizures per day Closed head injuries with loss of consciousness, nausea or vomiting Acute mental status change Suspected TB Drug overdose

8. Federal and State can have huge medical facilities May have hospital wards with several beds up to full ward equal to a secondary hospital Some institutions have mobile unit come to parking lot Usually no ultrasound, MRI,PET (positive emission tomography) or CT Majority of injuries are sports or work related So you may get them at your hospital or clinic!

9. Extensive logistical planning to get pt to hospital Correctional environment well controlled, have cameras aimed at all areas Once the prisoner is outside the correctional institution, all bets are off Vulnerable to possible escape attempt or gang attack to free member Prisoner comes in handcuffed, possibly shackled May be several armed guards, usually from sheriff’s dept. Transporting Inmate

10. Ethics Prisoners should be treated with same kindness, compassion and professionalism as any other pt. Provide sound and visual privacy when possible However, safety of yourself and others must be considered! All inmates should be considered to be potentially violent

11. Safety considerations Introduce yourself with title only, not your name Remove or cover name tag Turn film badge backwards Remove any personal effects in area that might help inmate find way to contact you

12. Safety tips cont’d Remove sharp objects or anything that could be used as a weapon Remove any drugs from room! Do not give pt newspaper, access to restroom or visitors Do not ride in same elevator as correctional pt Do not discuss time, date or location of next medical business with prisoner

13. Correctional Pt’s Attitude May be scared and confused in strange environment May have mental disturbances such as paranoia May be going through drug withdrawal May not be good at following directions May not like being told what to do! May have poor impulse control May become belligerent and uncooperative May think you look pretty cute!

14. Finding out what prisoner is in for… Don’t do it! It may compromise your ability to treat pt without bias Guards, guns and handcuffs tell you all you need to know!

15. Engage in friendly conversation If you have a death wish! Most inmates will be friendly and are grateful for a little adventure –some aren’t! Avoid having personal conversations with inmate or with others within earshot of inmate – (You don’t want to inadvertently reveal personal information about yourself, family or co-workers) Do not share e-mail or phone # Prisoner may try to gain your sympathy and manipulate you to help him/her out in some way Do not distract correctional officer with idle conversation Some released inmates commit crimes to return for continued health care!

16. Work around restraints If possible, leave all restraints on and be creative If they must be removed to perform exam ( by officers, only at their discretion !) leave leg shackles on for upper body, handcuffs on for lower body Have them put back on ASAP Plastic ties may be used on feet or wrists during CT or MRI Make sure deputy stays close by! (major cause of hospital escapes, injuries and death are because officer not vigilant!)

17. If Inmate begins acting hostile or strange: Position yourself close to the exit door Step back cautiously never turning your back Immediately enlist aid of every deputy in earshot!

18. Science of using X-rays and other imaging technology to assist in investigating and gathering evidence for use in a court of law, in civil and criminal cases Radiologist becomes a detective Radiographer has key role in producing the images that will serve as clues and evidence Forensic Radiology

19. Brief history of Forensic Radiology Ability to produce images using x- radiation was discovered in 1895 (considered to have had largest impact on medicine in history) Within weeks, man shot another man in leg – Bullet not found by probe or physical exam – Wound healed, but remained symptomatic – Received x-ray, bullet found, shooter convicted of attempted murder, got 14 years in jail

20. Considerable controversy at time One judge refused to admit x-ray as evidence- claimed it was “like using a picture of ghost” Dec 1896 judge handed down landmark decision allowing x-rays to be used as evidence Main problems: – up to 70 minutes to produce image – huge dose radiation dose

21. Uses of X-ray for Forsenic Radiology Investigating suspicious deaths and murders – X-rays of deceased taken prior to autopsy sometimes reveal cause of death, or suspicious circumstances Analyzing "adverse medical events“ – During a hospital stay or medical procedure, something goes wrong -causing injury to pt, forensic radiology can provide clues and evidence of what has happened Legal Matters---in assault, X-ray shows proof of injury Child Abuse Cases---evidence of acute and chronic injury Drug Trafficking---determines if suspect smuggling drugs by ingestion or insertion into body cavities

22. Adolph Hitler After war, speculated and rumored he had not committed suicide and not dead Antemortem (before death) skull x-rays were found showing distinctive dental work Burned remains were x- rayed, positive ID made

23. Dr. Josef Mengele “Angel of Death” in Germany during WWll – Performed surgeries without anesthesia – Experimented on twins then killed them and dissected bodies – Limbs cut off, isolation experiments, froze victims to death – Injected bodies with different chemicals to see how they would responds – When he was done, person sent to oven Escaped after war Went from Germany to S. America-practiced medicine In 1985 a body was found purported to be his Corpse x-rayed found to have abnormalities consistent with known accidents and illnesses but no antemortem radiographs to compare Family reluctantly gave up dental x-rays -result positive ID

24. Fingerprinting In late 1800’s tips of fingers lightly coated with powered lead teroxide and radiographed revealing fine fingerprints Ink replaced- cheaper and faster – Lead dust a health hazard Now a method used for recovering latent prints on difficult surfaces (wax, cardboard, cloth, skin) – Uses XFR: (X-ray Fluoresence Radiography) uses emission of secondary or “compton scatter” when bombarded with high-energy x-rays

25. Mummies Detection of hidden valuables, age, sex, embalming methods injuries and diseases

26. Volume-rendered image of CT Mummy

27. Never trust anyone! One attorney x-rayed a will on parchment – Radiograph showed it was extremely thin in one area, suggesting some names were erased, others added

28. Standards and Credentials There is none! Anyone can read or take images with no additional training X-rays often taken by people with no training No consistency, positioning not accurate - difficult to match and compare postmortem with antemortem studies

29. Advantages of being Forensic Radiographer Pt never has to get up to go to bathroom Pt never complains of waiting too long Never breaths in middle of exam Never moves in middle of exam Doesn’t have to be shielded Doesn’t complain about repeats or too much radiation exposure

30. Body Bags Initial fluoroscopy screening of body bags prevented pathologists from harming themselves on unexpected sharp objects Forensic radiographers have on rare occasions found unexploded grenades!

31. Forensic Radiography can: Find bullets that may have migrated to be used as evidence in court Detect fx’s in suspected child abuse cases Help determine causes of death Along with dental records and DNA analysis, radiological images can identify unknown victims Give families closure ( by body Identification) even from as far back as Korea and Viet Nam Makes possible to issue a death certificate (id) so wills may be probated, death benefits paid out, or spouses can remarry (otherwise must wait 7 years to be declared legally dead)

32. World Trade Center Huge team of fingerprint examiners, anthropologists, radiologists must work together for ID Forsensic odontologist- works with dental charts Forsensic Anthropologist- determines height, weight, ethnic group, sex

33. Forensic Radiologist can: ID body from fX’s, surgeries, diseases even phleboliths in abdomen

34. Determining Sex of Victim

35. Age Determination Can be accurately determined from 20 th week of gestation until early adulthood (using dental and bone age exams) Over age 25 difficult to determine biological age of person

36. Art Forgery Some art dealers claim that 15% of all art pieces sold at auctions are fake Past curator at Metropolitan Museum of Art in New York stated approx 40% of all art pieces proposed to him for purchase by museum were forgeries Throughout history canvas and wood panels have been very expensive so many artists just painted over the top of previous paintings Sometimes as many as 7 times (layers underneath known as “underpaintings”)

37. Art Forgery cont’d Legitimate art may have underpainting (or be an underpainting!) Alleged painting by Picasso (Absinthe Drinker) was found to have abstract painting below it which historically is impossible Another painting was alleged to be painted by Strigel in 1460. After being radiographed, a painting by another artist who lived 250 yrs later was found underneath it

38. Van Gogh

39. Master Forgers Yves Chaudron: (C 1900) Reputed to be one of most gifted counterfeiter in art world A respected conservator but really a master forger Would copy great paintings which had been lost or stolen, which his collaborator would then sell collectors Most notoriously responsible for copying Mona Lisa after 1911 painting theft from Louvre

40. Migrant Worker Smuggling Bust 513 migrants packed into 2 trucks Each paid up to $ 7,000 USD for trip from Guatemala to United States, risking life in order to find work

41. Drug smuggling

42. Airport Scanner

43. Effects of x-raying scanning on film at airport

44. Courtroom Testimony Radiologic technologist could be called into court to testify under oath as “fact witness” – Product liability – Personal liability – Property liability – Malpractice – Testifies only about what can be perceived by 5 senses (proper ID of Pt, labeling, procedure etc) Radiologist may be called in as “Expert witness”- not only testifies on basis of personal knowledge- but offers opinion – Simplifies complex or scientific issues for easy understanding by those with no experience

45. MRI and CT Studies have shown that “digital (or Virtual) autopsy” can be very useful, possibly replacing classic forensic autopsy – Faster – Cheaper (30 minutes vs several hours) – Leaves body intact – Images can be reconstructed in different ways

46. Three-dimensional volume-rendered image of skull Shows comminuted fracture of posterior skull

47. Is you diamond fake? Real diamonds do not show up on an x-ray Glass, cubic zirconium and crystals all have slightly radiopaque quailities Diamonds are radiolucent