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September 11, 2006

Forensic Radiology — Dead Men Do Tell Tales
By Meghan A.T.B. Reese
Radiology Today
Vol. 7 No. 18 P. 12

In fact, they speak volumes about how, when, and where they died and how, when, and where they lived.

With the widespread popular culture buzz about the “CSI effect” seeping into courtrooms and trial proceedings, anyone who watches CBS at 9 pm on Thursdays can tell you forensic science involves autopsies, examining evidence, data comparison, and often some unique methods of uncovering truths. But as of yet, television has rarely shed its pale light on radiology as a forensic science. Most people are unaware of the vital information gathered by those not portrayed on television series, including forensic radiologists and technologists.

“I think the producers have been a little leery of featuring forensic radiology because they are worried that it might be a little too sophisticated for their audience, but I don’t think that’s true,” says B. Gil Brogdon, MD, university distinguished professor emeritus of radiology at the University of South Alabama Medical Center in Mobile. “Americans are fairly understanding of x-rays and CT scans at the present time. It’s a bit esoteric for some people, but I think it is going to happen and is starting to happen now.”

Forensic radiographers and radiologists have long been important members of the forensic team. But with recent natural disasters such as Hurricanes Katrina and Rita and the manmade disaster of war, many more are coming to acknowledge the contributions of radiologists and radiographers.

Let the Dead Teach the Living
While this summer’s blockbuster movie pirates will tell you that “dead men tell no tales,” forensic science experts know differently. In fact, they speak volumes about how, when, and where they died and how, when, and where they lived.

On one level, the tales of Hurricane Katrina’s victims serve as a warning to those who attempt to face off against the forces of nature. But what have the dead communicated to the living, to be extracted as a lesson for going forward? Aside from the geopolitical ramifications and the backlash incurred from Katrina, the medical community has a greater appreciation of the necessity in recognizing radiology as a pertinent part of the forensics team. Doctors in a makeshift mortuary in St. Gabriel, La., posted a hand-lettered Latin sign: Mortui vivis praecipant, which means “Let the dead teach the living.”

Through recovery operations after Hurricane Katrina and other disasters such as the tsunami that leveled the Thailand coast, the Oklahoma City bombings, and World Trade Center identification efforts, radiology is carving its own niche in forensic science. Fingerprints, autopsies, and physical examinations often state the obvious. Forensic radiography and radiology offer insight into what cannot readily be seen. In addition to the examination of the body, radiology can provide other clues surrounding forensic investigations. X-ray can determine whether a gun is loaded. If a weapon is rusty or corroded, a radiograph gives valuable information on the overall firing condition. Radiographs showing the area surrounding a bullet penetration provide useful information on the type of bullet, firing distance, and origin. X-ray can assist in displaying the “splatter pattern” caused by the discharge of the weapon. Additionally, altered, hidden, or distorted serial numbers may be visualized in radiographs.

Regardless of the long list of reasons why radiography and radiology could and should play an integral part in the forensic community, many don’t hear the calling for it—often because there isn’t one. “Most people who do forensic radiology do so as an avocation. Radiology is in short supply, so many people don’t have time for this activity and many people are not aware of the possibilities,” says Brogdon, who has been conducting work as a forensic radiologist for nearly 40 years and has written the only English-language book on the subject. “The spectrum of what one can do with forensic radiology is quite broad, and largely not very well appreciated.”

Brogdon’s work has run the gamut of forensics. “It ranges from identification of bodies to evaluation of pattern injuries. We get involved with murders, attempted murders, assault, sexual activity, cases of abuse in children and adults, examining artifacts, fraud cases,” he says. “Radiology is used extensively now to trap drug smugglers, body packers. I’ve been involved in four cases of police brutality or excessive force, and of course mass casualty operations.”

Radiology has played a role in high-profile situations such as the Terri Schiavo case. In the course of treatment after her heart stopped, Schiavo underwent 23 chest x-rays, three brain CT scans, two abdominal radiographs, two echocardiograms, one abdominal ultrasound, one cervical spine radiograph, and one radiograph of her right knee. Those tests were compared with a 58-image postmortem radiologic survey of her entire body that was performed using a digital fluoroscope x-ray. A second radiologic examination was performed later, capturing an additional 28 images, including multiple views of her anterior neck structures, torso, and pelvis.

Despite the myriad uses, forensic radiology and radiography are seemingly but a blip on the radar of public awareness. And if the public is not aware, there is little chance the government will be the first to lend a helping hand through funding. “Radiographers have been remarkably underused in forensics so far and there are several reasons for that,” Brogdon says. “One being there is a shortage of radiologic techs and they are hard to come by and thus reasonably well paid.” Many medical examiners’ (MEs) offices simply cannot afford a full-time medical radiographer. “Some MEs’ and coroners’ offices really don’t understand the value of having such a person,” he says.

“Another problem in the United States is that funding for forensic [radiology] may be provided on the county level, maybe at the state level, maybe at the federal level, any combination of those. It is not a terribly hot-button item in political activity, so it sometimes falls through the cracks,” Brogdon says. “There’s a lot of radiography done in this country in morgues and coroners’ offices and by anthropologists that is really pretty badly done and it could be improved a great deal. So funding is a big problem, and education and understanding the value of a radiographer is a big problem.”

Putting the RT in DMORT
Only after the 140-mile-per-hour winds died down and the 30-foot storm surge and heavy rains subsided did the numbers start to pour in: more than 1 million people displaced, thousands missing, and hundreds already confirmed dead. In the aftermath of Hurricane Katrina, the first response to deal with the human death toll came from Disaster Mortuary Operational Response Teams (DMORTs). These federal-level response teams provide mortuary assistance in the case of mass fatalities or a cemetery-related incident. They cover temporary morgue facilities, victim identification, forensic dental pathology, forensic anthropology methods, processing, preparation, and disposition of remains. A DMORT is composed of private citizens, each with a particular field of expertise, who are called upon in the event of a disaster. Nancy S. Adams, BS, RT(R), clinical coordinator for the radiologic technology program at Itawamba Community College in Fulton, Miss., is x-ray team leader of the Region 4 DMORT. This was not the first mass casualty deployment for Adams who also served with the DMORT operation in 2003 at the Rhode Island nightclub fire that killed 96.

Less than two dozen radiologic technologists are on the DMORT of nearly 1,200 to 1,500 members nationwide. With those sparse numbers, the need for trained technologists is obviously great and was blatant with the Katrina deployment. “The devastation was so widespread and there were so many bodies. There were only three technologists,” Adams recalls. “With the number of bodies we were dealing with initially coming through there, we needed twice as many. We really needed to be running two teams of x-ray simultaneously.”

Aside from being grossly understaffed, the conditions were often barely conducive to conducting x-rays. Adams recalls having no access to digital radiography, employing only cassette and darkroom processing. Much of the equipment had not been serviced since it was stored years prior. There were malfunctions, dead batteries, and no spare parts. Some cassettes were unusable, and speeds did not match. Film was outdated and no personnel were trained in equipment repair.

But it’s not the difficult circumstances that most carry away from deployments. At peak workload, in an eight-hour shift, 15 to 20 bodies were imaged, with an average of 10 images per storm victim. “For a lot of people, this was a life-altering experience. There were people who had never dealt with a dead body and had no idea what to expect,” Adams says. “I have had people on the team tell me, ‘When I went back home, I had a really rough time dealing with it.’ I think a lot of us felt that way. Psychologically, if you let it, it could be very demoralizing. You can’t dwell on it. For someone who had never dealt with that, it could cause some serious emotional problems.”

Adams has been doing forensic x-rays since her days as a student, possibly making her more mentally ready. “I was prepared,” she says. “I’ve been there and dealt with the human body in almost every conceivable condition over the years, so I knew what to expect. I hate to say this, but it was an awesome experience. It gave me the opportunity to bring my skills in and help in identification. I think maybe I missed my calling.”

The Bare Bones of Forensic Radiography
“Nobody in the medical profession—and that includes physicians and radiologists—nobody looks at as many images,” Adams says, “and we don’t interpret the images for diagnoses, but we look at image quality, we critique it for anatomy, etc. One thing technologists bring to the table is in-depth knowledge of anatomy and particularly skeletal anatomy. A well-trained technologist can take a disarticulated skeleton and put it together correctly.

“People think all we do is push a button and they don’t realize what has to go on in that brain to push that button correctly,” Adams adds.

“The condition of the body may cause modification of the x-ray technique employed. You have to modify the exposure factors a great deal in burned bodies or bodies that have been submerged in water as opposed to fresh bodies. All these things affect the images we will eventually get. This is where experienced and trained technologists can do a much better job,” Brogdon says. “Unfortunately, mostly because of financial considerations, most of the radiology is done by untrained people. One of the old systems done in many morgues is they put a penny on the cassette that holds the x-ray film and they put the body on it, take the x-ray, and if they can see Lincoln’s head on the penny they think it’s good technique.”

“The exposure factors that determine the image quality is another factor technologists provide,” Adams says. “Also, the human body has to be placed in a particular relationship with the x-ray tube and the image receptor. It’s very important that the postmortem image is done as closely to the antemortem image for comparing them properly.”

“If you just throw a body in a bag and x-ray it, you’re not likely to get very useful information,” Brogdon says.

Adams remembers several instances where the radiographers greatly aided in identification of victims as well as pointing out anomalies that could lead to a positive match. “There was a young individual, but the pathologist thought it was conceivable that this person, upon visual inspection, had open-heart surgery,” she says. “We did a chest x-ray first and sure enough there were sutures, which told the pathologist a lot right there. In cases of [a patient with a] prosthesis, that immediately reduced the amount of time the pathologist would use because all you had to do was excise the prosthesis and get the serial number.”

Additionally, Adams says, “We had an antemortem x-ray of a patient’s knee and it showed some degenerative changes. So I went back and did an identical projection on the body we were trying to identify and we were able to say definitely that it was the same individual. There are a lot of qualities and experience that a technologist has that really no one else has.”

Radiologists generally work strictly with the living, but technologists may work with deceased. But there are stark differences. “With your living patients, you run into problems with cooperation, movement, and, of course, you don’t have that with a cadaver. But what you do have is decomposition and that plays a very vital role in how we set our technical factors,” Adams says. “A body that has been dead only an hour is not a problem, but a body that has become bloated and so on presents challenges.”

Insect activity, varying states of decomposition, and the formation of adipocere (the changing of the body’s fats into a soapy wax through hydrolysis) may affect images. “We saw a lot of adipocere in Louisiana because of the cemetery washouts. It doesn’t affect the technical factor but the image itself—adipocere shows up in the image—so you have to know what to look for,” Adams says. “Another problem was the clay and that adheres to bodies like glue and that affects the images as well and can be misleading initially.”

Something people don’t realize, which has come to the forefront with the London bombings, mass graves, and suicide bombers, is that inside the cadaver there may be unexploded ordinances or sharp pieces of shrapnel. “These are all things that you need to look for in an x-ray before you go digging into those bodies because you can do yourself some serious harm otherwise,” Adams says.

Where It’s Going
Forensic radiography started gaining clout through work done in the Balkans with the discovery of mass graves and other atrocities. In cases of war and torture, radiology provides important tools in discovering information that seemingly died with its victims. Some firearms produce a characteristic x-ray pattern and x-rays can detect characteristic bone fractures, blood, and edema. MRI may reveal the tendon thickening and ulcerations when initial signs of injury have disappeared. MRI has also been used to confirm claims of electric shock torture by identifying signs of tissue damage where electrodes were attached to victims.

Sophisticated methods of examining bodies and body parts are being employed around the world to further advance forensic radiology. At the Charles C. Carson Center for Mortuary Affairs at Dover Air Force Base, they use fluoroscopic images and CT scanners to examine the remains of soldiers who die in military service. The exam may give information that may be missed by conventional autopsy. In Bern, Switzerland, MEs are routinely doing CT and MRI examinations before autopsies and then comparing the two methods’ results. Brogdon notes that this is not a replacement for the autopsy but a supplement to it. But that notion may not be too far off, says Adams. In situations where religious belief or cultural taboos prevent autopsies, this can at least be a reasonable substitute.

“We are seeing more virtual autopsies through CT and MRI,” Adams explains. “We are seeing more people who object or even forbid any type of invasive autopsies—like some Muslim and Orthodox Jewish faiths. Plus more people [generally] object to having their loved ones cut open so, we are seeing a trend toward imaging.”

Timothy McVeigh, convicted of killing 168 people in the 1995 Oklahoma City bombing, opposed an autopsy for ethical and philosophical reasons prior to his execution in 2001. His request to not have an autopsy performed was upheld, but he agreed to a noninvasive x-ray autopsy.

“From the Balkan mass murders to the London bombings to Hurricane Katrina and beyond, there is a great need for additional education for people who want to go into forensic radiography and develop standards nationally and internationally,” Adams says. “We see a need for recognition of radiology as a forensic science.” Development of an American chapter of the International Society of Forensic Radiographers is underway, being led by Adams, which Brogdon highly regards because of the potential for cross-education and cross-information.

“In general, we are lagging behind [in the United States] in that the Brits and Europeans are making much bigger use of both their radiographers and radiologists and have a greater understanding of what they can accomplish,” Brogdon says.

— Meghan A.T.B. Reese is assistant editor of Radiology Today.