Bodily injury resulting in death. The guy miraculously survived after terrible injuries

A woman applied to the Commission for Church Social Activities. Her 27-year-old son is seriously ill, he barely survived after a traumatic brain injury. Eight months mother and son spent in hospitals, and now that Andrey was discharged home, Galina Vasilievna was forced to purchase a functional bed for him, such a patient cannot lie on the couch. I had to buy a medical bed for 58,000, the bed is good, with a control panel, but the money for it was borrowed, how to give it back is not clear
Collected funds for February - May 57,000 rubles. REQUEST IS CLOSED! Thank you!

Collected for February - May 57,000 rubles. REQUEST IS CLOSED! Thank you!

A woman applied to the Commission for Church Social Activities. Her 27-year-old son is seriously ill, he barely survived after a traumatic brain injury. Eight months mother and son spent in hospitals, and now that Andrey was discharged home, Galina Vasilievna was forced to purchase a functional bed for him, such a patient cannot lie on the couch.

What happened to her son, Galina Vasilievna still does not know. Most likely he was severely beaten. Here is what she told our correspondent: “At eight o'clock in the evening on September 8, he left. I tell him: “Son, warm up dinner?” And he says, "Mom, I'll be right back." And didn't come. I waited all night. In the morning I started calling his friends. No one knows. Phone and passport at home. I called the accident bureau. They gave me the numbers of the hospitals where the unknown people were admitted tonight. I went to one of the hospitals. I went up to the floor and saw his things on a gurney.

Andryusha at that time was undergoing an operation, a craniotomy. He was operated on for eight hours. And then the doctor came out and said that he had an injury incompatible with life.
Closed craniocerebral injury, removed two huge hematomas. He has total aphasia - there is no speech. He understands everything, he hears me. And he sees with one eye. And also paralysis of the facial muscles, he can’t blow, he can’t pronounce “y” “and”, a special speech therapist worked with him in the rehabilitation center, the results were good, he even began to blow a pipe.

We spent eight months in hospitals, in neurosurgery, then in neurology, then we were in Zvenigorod in a rehabilitation center. They brought him there half-dead, he was completely paralyzed, and now his left arm works, he even tries to hold a spoon.

Galina Vasilievna is 55 years old, recently she confessed and took communion for the first time in her life:
“I didn’t go to church before, I started going to the hospital. There was a prayer room at the hospital. I saw an ad in the elevator and went there. Then the priest began to come to our ward. There is a temple 10 minutes walk from this hospital, father N. serves in this temple, he saw our plight, supported and even helped financially. I confessed to him for the first time in my life. And I unctioned my son
And then in the rehabilitation center we took communion every week, the local priest went to our ward.

We haven't been home for eight months. And here is the fifth day we are at home. I imagined it would be hard, but I didn't think it would be to this extent. We are together, always together. I only go out for milk and bread. I run out. After all, you can’t leave him alone - epistatus, an attack can happen at any moment.

In eight months I have already learned how to care for him. In the rehabilitation center, we tried to put him on his feet. There was a Swedish wall, they were not advised to buy a Swedish wall to teach him how to stand, so that he would feel the ground under his feet. I went shopping - expensive walls and bulky, we have a small room, a non-standard wall is needed. There is a furniture factory not far from us, I went there, tried to explain my situation, my position ... They told me: “What have we to do with it?” I went to another factory. The director says: “I have an assembly shop, I don’t have any materials or machines ... But you leave your phone just in case.”
And you know, today he called and said that they made a Swedish wall for us, they did it in Kursk. And today they will bring it to us and install it. But he didn’t take any money from us… To my shame, I don’t even know his last name, his name is Vyacheslav Pavlovich.

Galina Vasilievna still cannot get used to her son's illness. He sorts through the details of life in his memory: “Before his illness, Andrei worked as an electrician. After school he entered the industrial institute. At school he played in the school theater. I went to a technical university, but I was not a techie, I entered the architectural one for five years in a row. He draws wonderfully. He is completely out of date, Okudzhava also loves Yesenin. Friends came to the hospital, but, unfortunately, he did not recognize them then. He is completely non-confrontational. I don't even understand who and why. He said, "Mom, I'll be right back."

Friction (sliding)- mechanical interaction of a traumatic object and a body moving in a tangential (tangential) direction relative to each other. Occurs when a traumatic object slides over the surface of the body or vice versa. Leads to the formation of extensive abrasions.

Stretching - the action of two or more traumatic objects on the body. The action of forces is centrifugal. Breaks and gaps are formed.

Concussion - a sharp inertial displacement of the organs of the human body with strong impacts in the direction opposite to the direction of movement. The general impact concussion of the body is accompanied by damage to the fixing and ligamentous apparatus of the internal organs, hemorrhage in the roots of the lungs, rupture of the gates of the kidneys, etc.

CAUSES OF DEATH AT MECHANICAL DAMAGE

Gross anatomical violations of the integrity of the body with massive damage to vital organs. Some injuries exclude even short-term preservation of life, for example, traumatic separation of the head from the body, separation of the body, crushing of the head, neck, chest, abdomen, crushing and rupture of vital organs - the brain, heart, lungs, liver. In such cases, it is customary to talk about damage that is not compatible with life.

Reflex cardiac arrest. A special place is occupied by damage to the reflexogenic zones (neck, chest, abdomen, perineum), the injury of which is accompanied by sudden cardiac arrest. With external and internal studies, no visible morphological changes are detected or they are insignificant. Many researchers believe that "reflex" death in such cases is possible only in the presence of diseases of the cardiovascular system. An objective assessment of the circumstances of the case, minimal anatomical damage, forensic histological examination, consideration of the state of the cardiovascular system and the exclusion of other possible causes of death allow us to correctly formulate a forensic medical diagnosis.

Most often, death occurs from life-threatening injuries internal organs and large vessels, which usually require emergency medical care, and in its absence or ineffectiveness trigger the following thanatogenesis mechanisms.

Acute massive blood loss. For the onset of death, not only the amount of blood loss is important, but also its rate. When large vessels are injured, acute blood loss develops over a short period of time and leads to death in the first minutes after injury from fibrillation.

ventricles. In such cases, the picture of anemia does not have time to develop

and show signs of rapid death; damage to a large vessel; cadaveric spots of normal intensity; anemia of the brain

and heart muscles with normal blood filling of other organs; Minakov's spots - banded hemorrhages under the endocardium of the left ventricle.

With a slow rate of death, blood depots have time to unload, developing signs of acute anemia: pale skin and mucous membranes; pale island cadaveric spots; anemia of internal organs, their pallor and dryness; flabby, shriveled spleen; sometimes Minakov spots. The kidneys have a characteristic appearance on the cut: the cortical substance is anemic, light red in color, in a pyramid of a darker color. Histologically, capillary emptying or filling with plasma, arteriospasm, later replaced by atonic expansion of larger vessels, leukostasis and leukocyte thrombi in capillaries are detected.

and venules due to the release of leukocytes from the depot. Later, due to hypoxia, cerebral edema, hydropic dystrophy of neurons and nephrothelium develop with a transition to necrosis. Fragmentation of muscle fibers is observed in the heart, foci in the lungs emphysematous-dilated alveoli.

traumatic shock- a universal response of the body to damage, expressed in deep disorders of the central nervous, endocrine and cardiovascular systems, manifested in the development of blood and plasma loss, peripheral circulatory insufficiency and a discrepancy between the volume of circulating blood and the capacity of the vascular bed. It reaches its full development, as a rule, 5-10 hours after the injury.

Clinically, shock is manifested by the following symptoms: cold wet skin, slow blood flow, anxiety and (or) blackout of consciousness, lowering blood pressure, tachycardia, dyspnea, oliguria.

There are two phases of shock: erectile, which is characterized by mental arousal, elevated levels of catecholamines and glucocorticoids, relatively high blood pressure and short-lived adequate blood supply to the organs; torpid, when pressure (especially pulse pressure) drops, lethargy and a detailed picture of shock are observed. In the torpid phase, four degrees are distinguished: degree I - mild, degree IV - terminal, when coma and pronounced dyscirculatory changes occur in the internal organs with the development of insufficiency of their function and necrotic changes. Earthy skin, cyanosis of lips and nails.

Morphological signs of shock: the presence of severe trauma (damage to large vessels or parenchymal organs, reflexogenic zones); thickening of the blood; redistribution of blood (venous plethora, arteriospasm, pathological deposition of blood in capillaries, especially in the spleen, liver); "shock kidney" (ischemic cortex and full-blooded pyramids due to shunting of blood flow); signs of microcirculation disorders - edema of the stroma of organs, sludge, stasis; signs of DIC; foci of necrosis in the parenchyma of internal organs.

DIC constantly accompanies the development of shock and consists in a generalized violation of the rheological properties of blood, which is manifested by thrombus formation in capillaries and venules and generalized hemorrhages associated with the depletion of the coagulation reserve of blood during thrombus formation.

Morphological manifestations of DIC are the liquid state of the blood, multiple hemorrhages under the serous and mucous membranes due to increased permeability of the walls of blood vessels. In the long-term post-traumatic period, hemorrhages in the mucous membranes of the gastrointestinal tract, acute erosions, which can become a source of bleeding, are found.

Compression of vital organs by effusion of blood or air:

compression of the brain with intracranial hematomas, cerebral edema and its dislocation in traumatic brain injury; hemopericardium and cardiac tamponade; pneumothorax, especially bilateral.

Death from hemothorax almost never occurs in practice, since when bleeding into the pleural cavity, death occurs from massive blood loss before severe respiratory failure has time to develop.

Asphyxia due to massive aspiration of blood possible with incised wounds of the neck, fractures of the bones of the nose and the base of the skull, if blood enters the respiratory tract. Signs of death from asphyxia with aspirated blood are as follows: general signs of asphyxia; the presence of blood in the respiratory tract; characteristic appearance of the lungs due to multiple dark red areas under the pleura); histological examination of erythrocytes in the alveoli.

Emboli of several types. Air (gas) and fat thromboembolism are of expert importance.

Air embolism develops with cut wounds of the neck with damage to the veins; criminal abortions; imposition of pneumothorax (when the needle enters a large vessel). The outcome of the embolism depends on the amount and speed of air intake, with a small volume and slow intake

it can resolve without being fatal. Diagnosis is based on the use of an air embolism test and a histological examination of the lungs, in which cellular structures are found in the vessels - traces of air bubbles.

Gas embolism is associated with the transition from a high pressure zone to a zone with low or normal pressure, which is accompanied by the transition of nitrogen from a dissolved state to a gas phase (with the development of decompression sickness).

Fat embolism is a sequential entry of fat droplets into the bloodstream, their fixation in a small circle, accumulation and implementation in the form of a pathological process. Fat embolism develops with fractures of a long tubular bone, with crushing of the subcutaneous tissue, etc. The largest amount of fat is retained in the vessels of the lungs.

FROM the development of fat embolism, inflammatory phenomena increase

in lungs and necrotic changes in the cortex of the cerebral hemispheres, which is clinically manifested by increasing respiratory failure and acute cerebrovascular accident. Death from a fat embolism does not occur immediately after the injury, but after 12–18 h to 3–5 days.

Histological examination with staining of frozen sections for the presence of fat (color inset, Fig. 21) confirms the diagnosis of fat embolism.

Pulmonary embolism (PE) as a direct cause of death in mechanical injuries is rare. As a rule, these injuries capture the lower limbs and the pelvic region. Damage to the endothelium of the veins is accompanied by the formation of a growing thrombus, the detachment of which can occur several days or hours after the injury. PE can occur with trauma to veins affected by thrombosis. When struck, a thrombus can become an embolus.

Thromboembolism can be of non-traumatic origin, if prolonged physical inactivity and increased blood clotting lead to deep vein thrombosis of the lower leg, followed by separation of the thrombus. The mechanism of death in PE consists of a mechanical blockage of the lumen of the vessels and the cessation of blood flow in the area supplied by this vessel. As a result, pressure in the pulmonary circulation increases, first right ventricular and then left ventricular coronary insufficiency, collapse in the large circle, bronchospasm, respiratory failure and coagulopathy develop. This whole complex of development of acute circulatory and respiratory failure can be designated as "cardiopulmonary shock".

With PE, in the lumen of the right half of the heart, the pulmonary trunk and its branches, a thromboembolus is detected, the body of which is a layered conglomerate, and the tail has a uniform red color.

Syndrome of prolonged compression(traumatic toxicosis) occurs with muscle necrosis and is caused by the entry into the blood of decay products, primarily myoglobin and hemoglobin slags. This leads to kidney damage and death from acute renal failure. More often this syndrome develops during mass disasters. There is also a syndrome of positional compression, which is characterized by necrosis of muscle groups that are subjected to compression during prolonged stay in one position of the victim for at least 4 hours (alcoholic or drug coma, etc.). When examining a corpse in the compression zone, the subcutaneous tissue is saturated with a yellowish transparent liquid, the muscles are pale red (fish meat) with yellow necrosis foci. The kidneys are enlarged, plethoric.

Infectious complications mechanical damage are osteomyelitis, purulent meningitis, encephalitis, pericarditis, pleurisy, peritonitis, pneumonia, sepsis,purulent-resorptivefever, gas (anaerobic) gangrene and tetanus.

The cause of death can also be traumatic laryngeal edema leading to asphyxia, traumatic aneurysms and heart defects, intoxication with tissue decay products, and other complications of trauma. They do not develop immediately after the action of a mechanical factor and not in all cases, therefore it is usually (although unreasonably) believed that there is no direct causal relationship between damage and death from such causes.

Death can also occur with injuries that are not life-threatening in nature, but lead to dangerous complications due to the lack of timely medical care. For example, when the bleeding did not stop when wounding small-caliber arteries, the victim was in a state of intoxication and did not seek medical help himself, death occurred from massive blood loss.

In expert practice, there are cases when injuries that usually do not cause harm to health can cause fatal complications due to the diseases of the victim. So, with aortic aneurysm, even a weak blow to the chest area sometimes leads to rupture of the aorta, acute blood loss and death.

There is a certain relationship between the frequency of certain types of causes of death and the duration of the post-traumatic period (Table 1).

Table 1 . Causes of death from mechanical injuries in the dynamics of the post-traumatic period

Death in the first hours after injury usually occurs from acute blood loss, traumatic shock, embolism, asphyxia as a result of blood aspiration, blood pressure on vital organs.

With the duration of the post-traumatic period within one or several days, the causes of death are mainly due to reactions on the part of organs and tissues to damage on the systemic

and organism levels:

acute respiratory failure as a consequence of pneumonia, which is associated with stress disorders of pulmonary hemodynamics (“shock lung”);

edema and swelling of the brain of dyscirculatory-hypoxic genesis;

dislocation of the brain;

cardiovascular failure.

In 1 week or more after the injury, infectious (pneumonia, peritonitis, phlebitis) and non-infectious (thrombosis, endotoxicosis, secondary bleeding, intestinal obstruction) complications of traumatic injuries come first. The main ones in the genesis of these complications are microcirculatory and hypoxic-trophic disorders of organs and tissues in combination with a violation of the rheological properties of blood and a decrease in immune resistance.

The most common cause of complications of traumatic disease is pneumonia. In the post-shock period, it occurs in half of the deaths. In the etiology of post-traumatic pneumonia, direct damage to the lungs, aspiration of blood, vomit, cerebrospinal fluid (in case of traumatic brain injury), impaired drainage function of the bronchi and ventilation of the lungs, prolonged physical inactivity with restriction of the act of breathing, etc. are important.

With a duration of the post-traumatic period of more than a few weeks, the causes of death are associated with multiple organ failure with wound exhaustion (purulent-resorptive fever), purulent-septic complications (bacterial toxic shock, septicopyemia, chronic sepsis). Purulent-resorptive fever is understood as a complication of severe injuries associated with the presence of large granulating wounds and sequesters, which cause resorption of necrotic juices, as well as protein loss. This condition causes cachexia and widespread dystrophic processes in the internal organs.

With large intervals between injury and death, it is more difficult to establish a causal relationship between mechanical injury and death and to qualify the severity of the harm caused to health. For this purpose, a detailed study of the features of the clinical picture of traumatic disease, a thorough assessment of the results of laboratory and instrumental research methods are necessary.

CAPABILITY OF THE mortally wounded for active action

Cases are described when a person with an injury incompatible with life (craniocerebral injury, heart injury, etc.) performs complex, sometimes requiring significant efforts, for several hours.

actions: resists the attacker, uses another method of suicide, overcomes a considerable distance. This may be due to the fact that brain compression in epidural hematoma, hemopericardium, and massive blood loss develop gradually.

It is possible to reliably exclude the ability of the mortally wounded to take active actions only in the following cases:

separation of the head, dismemberment of the body, crushing of the head, neck and chest, massive destruction of the heart;

damage to the autonomic centers of the medulla oblongata due to rapid death;

damage to the cervical spinal cord due to immobilization;

diffuse axonal damage to the brain due to immobilization and traumatic coma.

When assessing the possibility of the victim taking active actions, it is necessary to take into account the presence of injuries incompatible with life, the localization and extent of injuries; the general condition of the victim (alcohol has an anti-shock effect, contributing to the performance of active actions); degree and rate of blood loss; the mechanism of thanatogenesis and the rate of death.

SUBMODULE FORENSIC DIAGNOSIS OF LIFETIME AND RECEPTION OF INJURY

Establishing prescription and survival of injuries is an important task of forensic thanatology.

Post-mortem injuries are formed with rough resuscitation aids, collapses, transportation of a corpse, autopsy (for example, a fracture of the horns of the hyoid bone); are deliberate - when mocking a corpse, staging an accident or suicide, dismembering a corpse in order to conceal a crime (color insert, fig. 22, 23). Post-mortem injuries can be caused by animals and birds.

Tissue responses to damage detected by modern research methods, provided that breathing and blood circulation are preserved, differ little both in the presence of higher nervous activity and in its loss. Therefore, for practical purposes, the following definition can be adopted: antemortem injuries- these are injuries caused while maintaining the vegetative functions of the body, among which the most significant is the function of blood circulation.

When establishing the survival of injuries, one should take into account experience phenomenon, consisting in the fact that almost all tissues and organs are able to retain vital properties for some time when the integrative homeostatic systems of the body are destroyed, that is, in fact, in a corpse. This imposes restrictions on the accuracy of determining the survival rate when damage is inflicted in the next few minutes after the onset of vegetative death.

Age of damage- the time elapsed from the moment of damage to death (in the case of examination of a corpse) or until the moment of examination (for living persons).

Local and general, macro- and microscopic reactions of tissues and organs to damage are used to determine the duration and lifetime of injuries. Local reactions of tissues are found in the area of ​​damage, general ones reflect the reaction of the whole organism to respond integratively to the occurrence of damage. The sequence of development of pointing reactions makes it possible to obtain data on the duration of the injury.

Post-mortem injuries will not cause these reactions, since under conditions of a persistent lack of blood circulation and blood oxygenation, the energy supply for all types of reactions is insufficient for their effectiveness.

LOCAL MACROSCOPIC SIGNS OF LIFETIME INJURY

1. Signs of massive bleeding at the scene (pools of blood, profuse blood soaking of absorbent materials, splashes), on clothing (heavy soaking in blood).

2. Vertical streaks of blood on clothes and on the skin of a corpse are a sign of being in an upright position after an injury.

3. Massive accumulations of blood in the serous cavities.

4. Intermuscular thick, gelatinous, exfoliating hemorrhages with the formation of convolutions.

5. Reactive tissue edema.

6. vascular thrombosis.

7. Swelling and redness in the area of ​​injury (through 5-6 hours after injury), the presence of purulent exudate, granulations, scar.

Intense hemorrhage in the area of ​​damage is one of the important signs of survival, since it indicates the preservation of cardiac activity and blood circulation after injury. With post-mortem injuries, there is no blood pressure in the vessels, but it can passively flow out of the damaged vessel and permeate the tissues.

in strength of their capillary properties. However, this bleeding is small, and hemorrhage in the tissue is impregnating, without delamination and clotting.

Reactive tissue edema usually develops in the early stages after injury, but it can also develop delayed - from 30 minutes to 3 days.

However, the most reliable differential diagnosis of intravital and post-mortem injuries is based on histological data obtained in a comprehensive study involving both traditional microscopic examination and the latest immunohistochemical and histochemical methods.

Damage to living tissues leads to the release of inflammatory mediators from the endothelium, resident phagocytes, mast cells, etc. So,

in in intravital wounds, the level of histamine, serotonin, leukotriene B4 is increased, which is not the case with post-mortem damage.

LOCAL MICROSCORIC SIGNS OF LIFETIME INJURY

When the skin and underlying soft tissues are damaged, a neurovascular reaction occurs in the form of an initial arteriospasm, which is replaced after a few minutes by inflammatory arterial hyperemia.

Naturally, hemorrhages are formed with a clear contour of erythrocytes in the area of ​​hemorrhages. Over time (after 5-6 hours), they undergo hemolysis and gradually turn into a brown homogeneous mass.

Then appear in the tissues inflammatory cells, first, segmented neutrophils, the marginal standing of which in capillaries and postcapillary venules is observed already 30–40 minutes after injury (color insert, Fig. 24). At the same time, the level of tumor necrosis factor (color insert, Fig. 24b), leukocyte interleukins (color insert, Fig. 24b and 24c) increases with a maximum by 6 h. The concentration of interleukin-6 increases later (maximally after 12 o'clock). To determine these mediators in the wound, an immunohistochemical study is necessary.

Appear fairly quickly inflammatory edema tissues (pronounced after 3 hours) and inflammatory exudation, in the elements of which it is easiest to detect fibrin (from the 1st hour of damage).

After 12 hours, the wound is clearly expressed leukocyte shaft. At this time, it is already possible to notice an admixture of monocytes and macrophages derived from them to the inflammatory infiltrate, which become predominant after 20-24 hours.

Determination of the severity of harm to health of injuries incompatible with life - an expert or legal error

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Determination of the severity of harm to health of injuries incompatible with life - an expert or legal error / Gimpelson E.A., Ardashkin A.P. // Mat. VI All-Russian. congress of forensic doctors. - M.-Tyumen, 2005.

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Examination of the corpses of persons who died a violent death, as a rule, is accompanied by the resolution of questions regarding injuries, in particular, the harm caused to their health, its severity. The resolution of this issue during the examination of corpses was provided for in clause 32 of the "Rules for the forensic medical determination of the severity of bodily injuries", currently used in relation to the Criminal Code of the Russian Federation. This procedure was also provided for in paragraphs. 25-25.5, canceled "Rules of forensic medical examination of the severity of harm to health". “Key words: “degree of severity”, “severity of harm” in the title of the named “Rules ...” and the “Rules ...” that preceded them, restrict their use only in cases of damage with a possible prevention of death. Meanwhile, in practice, there are various examples of classifying injuries incompatible with life as serious harm to health of various origins, in which the preservation of the life of the victims at the present stage of development of clinical medicine is impossible under any circumstances. Thus, experts often refer to serious harm to health as cases of mechanical damage that are clearly incompatible with life, for example, complete destruction of the brain, fractures of the bones of the vault and base of the skull with significant divergence of fragments, extensive ruptures of the lungs, cases of death from mechanical asphyxia (compression organs of the neck, drowning in water), not interrupted in its course, etc.

In our opinion, the formulation of an expert judgment (conclusion) on classifying such and similar injuries as injuries causing serious harm to health is an expert error.

Such an incorrect classification of injuries incompatible with life as serious harm to health has several prerequisites. One of them is probably the fact that there was a distinction in the "Rules ..." of 1928 of injuries into "conditionally" and "certainly fatal" and the subsequent exclusion of this distinction from the "Rules ..." of 1961. Some forensic doctors regarded this as the basis for classifying as serious bodily harm (previously serious bodily injury) on the basis of danger to life and those injuries in which life could not be saved. At the same time, the circumstance was overlooked that the exclusion from the "Rules ..." of 1961 of the concepts of "conditionally" and "certainly fatal" injuries did not cancel the medical criteria for the compatibility (incompatibility) of injuries with life.

Another prerequisite, in our opinion, is the insufficient clear definition of one of the two criteria for grievous bodily harm, “if it in itself caused death ...” in clause 25.1 of the “Rules ...” 1996. This is also perceived as a basis for referring to serious harm to health and injuries incompatible with life. Meanwhile, there are injuries that in themselves can cause death, but are not incompatible with life. Such injuries, in particular, include injuries to the reflexogenic zones (chest, neck, abdomen and perineum) and the so-called primary shock that occurs with injuries to the larynx, testicles, and nail phalanges, which are richly supplied with sensitive nerve endings.

The reasons for another property of classifying injuries incompatible with life as serious bodily harm, in our opinion, may be the following.

• Firstly, the uncritical attitude of experts to the resolution of the legitimate issue of the severity of harm to health raised by the person (body) that appointed the examination. The legitimacy of a question does not yet mean that the answer to it must correspond to the version of the person (body) who ordered the examination. It should also be borne in mind that the establishment of the severity of harm to health of injuries incompatible with life should not have independent and sufficient procedural significance for the qualifications of criminal actions (events), since the qualification of the actions of one person in relation to another depends on the direction of intent established by the investigative procedures. However, it is possible that the person (body) that appointed the examination, having formally approached the expert’s statement about the severity of harm to health in case of injuries incompatible with life, and, referring to the expert, may neglect the detailed clarification of the direction of intent and choose an article of the Criminal Code providing for a more benign punishment. .
• Secondly, the misconception of experts about the concept of “damage” and referring to it only the consequences of the impact of mechanical factors. This can be seen from the conclusions and conclusions of experts, which talk about no damage in cases of death from poisoning, hypothermia and other non-mechanical factors. Undoubtedly, these (non-mechanical) environmental factors are also damaging.
• Thirdly, assessment by experts on the severity of harm to health of injuries that occurred at different times each separately without a subsequent assessment of their totality.
• Fourthly, the possibility in some cases of a favorable outcome of asphyxia, which voluntarily or involuntarily leads experts to violate the norms of formal logic. For example, in cases of mechanical asphyxia, this is expressed in a confusion of the concepts of "mechanical asphyxia" and "asphyxia", which are not identical.

Based on the foregoing, we believe that the concepts of "incompatibility of injuries with life" and "severity of harm to health" are incompatible concepts. The first is a judgment about the inevitability of the onset of biological death, the second is a judgment about the preservation, in any case, the possibility of saving, the life of a person in case of damage received by him. From this it follows that during the examination of the corpses of persons who died from injuries incompatible with life, arising from the influence of various environmental factors (physical, including various types of mechanical asphyxia and hypoxic conditions that were not interrupted in their course, etc.), the criterion severity of harm to health can only be used for injuries in which life can be saved.

In accordance with these, we offer the following approximate options for the answers of experts to the questions of the persons (authorities) that appointed the examination, about the severity of harm to health in case of injuries incompatible with life.

Case 1: mechanical asphyxia, uninterrupted in its course and ending in death.

Output option: According to the materials of the case (the circumstances of the discovery of the corpse: removed from the water, found with a noose around the neck, the presence and severity of signs of intravital formation of the strangulation furrow, etc.), the data of the forensic medical examination, mechanical asphyxia was not interrupted due to the strangulation of the noose in its course, which caused irreversible, i.e. changes incompatible with life (damage) of the brain. In connection with the above, changes in the brain that led to death are not subject to assessment by the severity of harm to health.

Case 2: mechanical asphyxia, interrupted in its course.

Output option:

• a) Death of Mrs. ... followed from mechanical asphyxia interrupted in its course due to compression of the neck organs by a loop during hanging, complicated by bilateral drain abscess pneumonia, which is confirmed by ....
• b) Interrupted mechanical asphyxia was accompanied by gr. ... a pronounced complex of life-threatening phenomena, which is confirmed by the data from the ambulance call card and the medical card of the inpatient about the duration of loss of consciousness (at least one and a half hours) followed by stunning, motor excitation, neurological symptoms (lack of pupil reaction, uneven tendon reflexes), respiratory failure and hemodynamics (wheezing in the lungs, increased heart rate, lowering blood pressure). This condition (damage) was life-threatening and, on this basis, they are classified as serious harm to health.

We believe that it is not difficult to formulate conclusions without assessing the severity of harm to health of injuries incompatible with life, therefore we do not give examples of such conclusions.

Undoubtedly, establishing the compatibility (incompatibility) of damage with life in some cases presents certain difficulties. Therefore, it is hardly possible to make specific recommendations on establishing the compatibility (incompatibility) of injuries with life, applicable to each such case. We can only talk about the criteria for compatibility (incompatibility) of injuries with life, compiled on the basis of an analysis that includes taking into account the location of injuries, their nature, clinical and statistical data on the known outcomes of such injuries. For example, a penetrating stab wound with damage to the wall of the heart in the provision of medical care very often ends in a favorable outcome. However, with a gunshot wound to the heart, accompanied by a significant defect in its wall, one can hardly expect a favorable outcome.

With multiple injuries of several areas of the body, each of which is not incompatible with life, it is advisable, in our opinion, to proceed from the possibility of mutual aggravation of several complications caused by each injury (pathological condition) separately, for example, traumatic shock due to multiple injuries and massive blood loss.

Each trauma surgeon faces the problem of providing obviously useless assistance to a patient with severe injuries. The resolution of this issue is less complex when it comes to an adult patient who has developed traumatic cardiopulmonary shock as a result of blunt trauma. In pre-hospital conditions, resuscitation is usually not carried out if the patient has no pulse and no breathing. Similarly, a patient with a penetrating injury who has no pulse or breathing will not be resuscitated unless he shows other signs of life, such as pupillary response.
Adoption such a decision in the prehospital setting is more difficult if the patient is a child, or if the injuries are the result of electric shock or drowning.

When brought to the ER, trauma professionals need to respect the rights of the patient and be guided by the "Golden Rule" that they must treat the patient as they would like to be treated under the same circumstances. Two areas in which the question of the apparent futility of help usually arise are traumatic brain injuries and multiple organ failure. The trauma surgeon should discuss the expected outcome with the patient's family members so that the final decision is based on the opinions of different parties.

Often in period, immediately following the injury, the patient's relatives remain immune to such discussions, since the patient's state of health before the injury was probably normal; the surgeon should continue the discussion to overcome this reticence. The Ethics Commission and the priest can be effective intermediaries in such matters. Determining the appropriate patient status code is vital in these circumstances.

Problem obviously useless assistance to injured patients attracts special attention of lawyers when it comes to the possibility of euthanasia. Rules that a patient will not be resuscitated should only be applied after full discussion with the patient's family members. Failure to provide assistance needed to save a life is a crime.

Even if patient there is a document defining his will regarding resuscitation, or a "will of life" that prohibits cardiopulmonary resuscitation or prolonged intubation and ventilation of the lungs, in the event of an acute injury, these instructions may not be valid. Therefore, it is important to take into account the opinion of the patient's family members on this issue in the current situation. Physicians treating patients with traumatic brain injury too often have to deal with patients who are in a vegetative state. The futility of the treatment becomes obvious, and the patient's relatives should be made aware of this.

If a family members insist that the life of the patient must be maintained through all possible resuscitation measures, consultation with the ethics commission is required! In the event that this also proves futile, trauma specialists should use the least aggressive therapy, if there is a choice; this path will slowly lead to the inevitable outcome, namely death.

Such passive approach must, however, be applied within the law. Traumatologists should not throw down the gauntlet to society in general and lawyers in particular by using euthanasia. It is a constant endeavor of physicians and lawyers to resolve issues of useless treatment in the event that members of the patient's family insist on it. Euthanasia challenges the legal system; similar actions by Dr. Kevorkian of Michigan led to a jury finding him guilty of murder.

trauma surgeon it can be hard to come to terms with the thought of the futility of treatment if he miraculously managed to keep the patient alive after horrific injuries, but subsequently the patient developed permanent multiple organ failure. Consultation with a "dispassionate" surgical colleague can help develop the right attitude towards the situation. Often the circumstances are such that it is impossible to clearly define what is the "uselessness" of assistance.

In theory, futility means that one is sure of a negative result, regardless of which treatments are used. However, the law is designed to provide protection to society, while medicine is designed to provide the best care for the individual. In attempting the best possible care in such a situation, and also avoiding litigation, the trauma surgeon should act “as an ordinary, prudent, reasonable physician would do in the same or similar circumstances.” Adherence to this principle will help the trauma surgeon avoid accusations of leaving the patient without help.

Improper execution by a doctor his official duties, which may be the result of non-compliance with the standards of medical care, includes four elements, namely: the duty of the doctor; violation of care standards; direct causation resulting from non-compliance with standards of care; and subsequent injury or other harm to the health of the patient. If, in the opinion of traumatologists, further treatment is useless, then in this case there is no direct causal relationship, as well as harm to the patient's health caused as a result of insufficiently high-quality treatment. Maintaining a patient-physician relationship will assist in determining the most appropriate patient status code and subsequent organ donation discussions.

The New York Medical Gazette of 1888 describes a unique case of a sailor in a river tug pulling a barge with large boxes piled up in two tiers on the deck. By an absurd chance, just at the moment when his tugboat was approaching the bridge with a low arch, the sailor who was on the bow of the barge took it into his head to see if the fastening of the upper tier had weakened, climbed onto the lower tier and raised his head above the boxes. Since he was with his back to the direction of travel, he did not see the impending danger, and the lower sharp edge of the beam of the bridge span, like a razor, cut off a part of the skull about two inches above the right eye.

And then a real miracle happened. When the sailor was taken to the hospital a couple of hours later, he was still alive. The doctors began to treat the wound, not really hoping to save the unusual patient, when suddenly he opened his eyes and asked what had happened to him. But the miracles continued! When the doctors finished their work and bandaged the head, which had decreased by a whole quarter, the victim suddenly got down from the operating table.

He demanded his robe, declaring that he wanted to go home. Of course, they didn't let him go anywhere. And yet, two months later, Ross returned to the ship. The injury did not seem to affect him in any way. Occasionally he complained of dizziness, but otherwise he was a completely healthy person. Only 26 years after the accident, he partially paralyzed his left arm and leg. And four years later, when the former sailor was in the hospital, the doctors recorded in his medical history that the patient had a tendency to hysteria.

Considering the remoteness of the years, one could doubt the authenticity of this story. But medicine knows no less striking cases that took place much later.

In 1935, a child was born at St. Vincent's Hospital in New York who had no brain at all. And yet, for 27 days, the child lived, ate and cried, no different from ordinary newborns. His behavior was completely normal, and no one even suspected the absence of a brain before the autopsy.

In 1957, Dr. Jan Bruel and George Albee gave a sensational presentation to the American Psychological Association. They successfully performed an operation in which the patient at the age of 39 had to remove the entire right hemisphere. Moreover, to the great amazement of the doctors, he not only recovered quickly, but even after the operation he did not lose his former mental abilities, which were above average.

And in 1940, a 14-year-old boy was admitted to the clinic of Dr. N. Ortiz, who was tormented by terrible headaches. Unfortunately, he died two weeks later, and until the very end he was conscious and in his right mind. When the doctors performed the autopsy, they were shocked: almost the entire skull was occupied by a huge sarcoma - a malignant tumor that almost completely absorbed the brain tissue, which meant that the boy lived without a brain for quite a long time!

In the United States, while excavating, 25-year-old worker Phineas Gage was the victim of an accident, the consequences of which have entered the annals of medicine as one of the most incomprehensible mysteries. During the explosion of a stick of dynamite, a massive metal rod 109 cm long and 3 cm in diameter stuck into the cheek of the unfortunate man, knocking out a molar, pierced the brain and skull, and then, having flown a few more meters, fell. The most amazing thing is that Gage was not killed on the spot and was not even so badly injured: he only lost an eye and a tooth. Soon his health was almost completely restored, and he retained his mental abilities, memory, gift of speech and control over his own body.

In all the above cases, the brain tissue was so severely damaged as a result of injuries or illnesses that, according to traditional medical canons, our "supreme commander" simply did not have to perform his functions as a thinking apparatus and regulator of vital processes in the body. It turns out that all the victims lived practically "without a king in their heads", although at different times.

But it happens that a person remains alive for some time without a head at all, although from the point of view of medicine this is absolutely impossible!

In the early 1950s, a good half of the students at the Military Institute of Foreign Languages ​​were former front-line soldiers. In the summer, when we went to military camps, in the evenings, as they say now, a talk club gathered in the smoking room and all kinds of stories from front-line life were told. Once Sergeant Major Boris Luchkin, who fought in regimental intelligence, told an incredible story. Once, while searching in the rear of the Germans, the lieutenant who commanded their reconnaissance group stepped on a jumping frog mine. "These mines had a special expelling charge that threw it up a meter and a half up, after which an explosion occurred.

It happened that time too. Pieces flew in all directions. Moreover, one of them completely blew off the head of the lieutenant, who was walking ahead a meter from Luchkin. But the decapitated commander, according to the foreman, did not collapse to the ground like a cut sheaf, but continued to stand on his feet, although he had only his chin and lower jaw left. There was nothing above. And now this terrible body unbuttoned the padded jacket with his right hand, pulled out a map with the route from his bosom and handed it, already covered in blood, to Luchkin. Only then did the slain lieutenant finally fall. The body of the commander, even after the death of "thinking" (!) About his soldiers, they carried out and buried near the headquarters of the regiment. However, then no one believed Luchkin's story, especially since the rest of the scouts who were walking behind did not see all the details and therefore could not confirm the words of the foreman. I confess that we, the students, also did not believe in the reality of the soldier's stories. But now the cases collected in my dossier make us treat her differently.

Medieval chronicles tell of such an episode. In 1636, King Ludwig of Bavaria sentenced a certain Dietz von Schaunburg and four of his landsknechts to death because they raised a rebellion. When the condemned were brought to the place of execution, according to knightly tradition, Ludwig of Bavaria asked Dietz what his last wish would be. To the great surprise of the king, he asked to put them all in one row at a distance of eight paces from each other and cut off his head first. He promised that he would start running without a head past his landsknechts, and those whom he managed to run past should be pardoned.

The noble Dietz lined up his comrades, and he himself stood on the edge, knelt down and laid his head on the chopping block. But as soon as the executioner took it down with an ax blow, Dietz jumped to his feet and rushed past the landsknechts, frozen in horror. Only after running the last of them, he fell dead to the ground. The shocked king decided that it could not have happened without the intervention of the devil, but nevertheless fulfilled his promise and pardoned the landsknechts.

Another case of "life after death" is reported in the report of Corporal R. Creekshaw, found in the archives of the British War Office. It describes the downright fantastic circumstances of the death of the commander of company "B" of the 1st Yorkshire Line Regiment, Captain T. Mulvaney, during the British conquest of India at the beginning of the 19th century. This happened during the hand-to-hand combat during the assault on Fort Amara. The captain cut off the soldier's head with his saber. But the decapitated body did not fall to the ground, but threw up a rifle, shot the English officer point-blank right in the heart, and only after that fell.

An even more incredible episode is cited by journalist Igor Kaufman. Immediately after the war, in the forest near Peterhof, a mushroom picker found some kind of explosive device. I wanted to examine it and brought it to my face. There was an explosion. The mushroom picker was completely blown off his head, but he walked two hundred meters without it, and three meters along a narrow plank across the stream, and only then died. The journalist emphasizes that this is not a bike, there were witnesses, and the materials remained in the archive of the criminal investigation department.

It turns out that even a sudden and complete loss of the brain does not at all entail the instant death of a person. But then who or what controls his body, forcing him to perform quite reasonable actions?

To answer this question, let's turn to an interesting hypothesis of Doctor of Technical Sciences Igor Blatov. He believes that, in addition to the brain and the consciousness associated with it, a person also has a "soul" - a kind of "repository of programs" that ensures the functioning of the body at all levels from higher nervous activity to various processes in cells. Consciousness itself is the result of the action of such software, that is, the work of the soul. And the information that makes up the software is embedded in DNA molecules.

According to the latest ideas, a person has not one, but two control systems. The first includes the brain and nervous system. It uses electromagnetic pulses to transmit commands. In parallel, there is a second one - in the form of an endocrine system, in which special biological substances - hormones - are carriers of information.

The Creator also took care to ensure the autonomy of the endocrine command system. Until recently, it was believed that it consists only of endocrine glands. However, according to the doctor of medical sciences A. Belkin, at the eighth or ninth week of pregnancy, the brain cells of the embryo break away from their parent and migrate throughout the body. They find a new home in all major organs - in the heart, lungs, liver, spleen, gastrointestinal tract, according to the latest data - even in the skin. Moreover, the more important the organ, the more there are. Therefore, if for some reason our "commander in chief" - the brain - ceases to perform its functions, the endocrine system may well take over.