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Forensics at UM: broad, innovative and multidisciplinary
When we think of forensic medical research, we usually associate it with crime investigation. But there's so much more to it than that. With no fewer than three forensics chairs, Maastricht University is unique in the Netherlands. Bela Kubat, professor of Forensic Pathology, Paul Hofman, professor of Forensic and Post-mortem Radiology, and Wilma Duijst, professor of Forensic Medicine and Health-Related Criminal Law, discuss the developments in their field. The first students of the new-style forensic medicine will graduate this year.
All three professors agree that with their different areas of expertise, they complement and strengthen one another. "It opens up doors for us to take great strides forward, and we're seizing that opportunity," Hofman says. "The Netherlands conducts fewer post-mortem examinations than almost any other country in Europe. Here we're always looking for the most cost-efficient way to achieve the highest quality result. There's a lot of room for improvement, but we're well on our way."
Final tool for healthcare quality
In Maastricht, clinical autopsies are performed not only in the case of crime investigations, but also to allow for the study of the healthcare system. What did the person die of? Did they receive the right treatment? Did anything go undiscovered? And what can all this tell us about the quality of healthcare in the Netherlands? Kubat: "Clinical autopsies are an important final tool in quality assurance. Research shows that, despite all the modern technologies in hospitals, there's a considerable discrepancy between what the attending physician considers the cause of death and what actually appears to be the cause of death. You can use the information obtained through a post-mortem to check the quality of your hospital. And doctors can learn from it too." Hofman: "This kind of research has been done in several wards at the MUMC+ where accurate records were kept of the cause of death according to the attending physician. The deceased patients were then examined using post-mortem radiological examination, and numerous autopsies were performed. The attending physicians turned out to have correctly determined the cause of death in only 50% of cases."
Kubat: "That's not to say that doctors are doing it wrong. The cause of death is often very difficult to determine clinically. We can look inside the body; something a doctor can't do with a live patient. It's important for both the next of kin and the doctor to know the correct cause of death. And it's important for national statistics, because they feed into the government's policy and funding of healthcare. The more accurate the statistics, the better the available money can be channelled towards the most prevalent types of disease."
Medicine and law
Forensic medical examinations conducted for the justice system typically involve many different people. It starts with the discovery of a body and the investigation of the crime scene. This is followed by an external inspection of the body; the domain of Wilma Duijst. Then there may be additional examinations, such as toxicological and forensic radiological examinations—Paul Hofman's remit. The next step is the autopsy, Bela Kubat's area. Duijst now wants to bring the medical and legal worlds closer together.
"It's so important for these fields to understand each other. Forensic physicians need to be able to produce clear reports, and the legal world has to learn to ask the right questions about these reports. We've got the ball rolling on several developments that will further professionalise the field, such as the new Forensic Medicine programme launched in 2018. The first forensic doctors will be registered in the Netherlands Register of Court Experts this year. We've had PhD candidates doing research in forensic medicine for several years now. There's a new scientific journal—the Nederlands Tijdschrift Forensische Geneeskunde—and the Handboek Forensische Geneeskunde will be published by Gompel & Svacina soon. I edited the book, and my colleagues Bela Kubat and Paul Hofman made valuable contributions."
The three professors place a great deal of value on forensics education, and consider it a pity that it is only an elective subject in the medical curriculum. Since all doctors inevitably come into contact not only with the death of patients, but also with victims of crime, they need some knowledge of the field—for legal as well as medical reasons. Who do you report findings or suspicions to? Who informs the next of kin? But there is a preventive aspect too, the professors say, because you can't recognise what you don't know. As a doctor, at some point in your career you will deal with victims of abuse, and it is important to recognise signs and injuries. Doing so requires dedicated training.
The forensics field is developing apace, especially when it comes to technological possibilities. Hofman: "We use all kinds of technical methods when examining the deceased, but by no means all the methods we have at our disposal. For example, we could do very good blood vessel tests or make more use of MRI. The latter is happening more and more often, but we're not yet making use of all the possibilities offered by this technology. It's our job to further develop this."
"Increasingly we want to be able to report at the activity level," Kubat says. "That means establishing not only that there's an arm fracture, say, but how that fracture arose; which direction the violent impact came from. For that you need a multidisciplinary approach involving radiology and other things. We already do that for gunshot injuries, where we reconstruct bullet trajectories and the direction of the gunshot injury. The goal is to do this in a much more complex way and in many more areas. In addition to medical disciplines, this requires technical disciplines, such as computer animations. The major challenge for the coming years is to bring together all the available information from all disciplines in a sound, objective way. Then you can develop detailed scenarios."
The crime scene in 3D
Hofman: "A few years ago we started a project together with the police and the Netherlands Forensic Institute. We're now seeing the first results. Imagine there's been a shooting; there's a body with injuries and bullet trajectories in the body. The bullets are examined, the investigators inspect the damage to walls, furniture, powder traces at the scene of the crime. This results in spatial information that the public prosecutor then has to piece together from various reports. What we've done is to create a visual representation of all that spatial information. The police make a 3D scan of the scene of the crime. That shows where the damage is on walls and furniture, where the victim is, and—in CT scans—where the injuries are located. So you get a picture of the entire crime scene. Then you can ask all parties—the police, witnesses and suspect—for their version of events. Based on the combined information in the 3D scan, you can check whether the scenarios described are physically possible."
Kubat and Hofman both worked on an army base on the investigation of the MH17 victims. Hofman: "That investigation had a lasting impact on everybody involved. I still think about it a lot." Kubat: "Every case is emotional, because there are always relatives who mourn the deceased. But there the circumstances and the scale of it had a huge impact. You carry that experience with you for the rest of your life." Duijst: "A lot of things stay with you in this field. A certain image—a house, a railway crossing, a photo—can trigger memories of a case. The one that most affected me was an accident in which a boy jumped from a roof to a tree. The branch broke and the boy died on the spot of a skull base fracture. I was the medical examiner. The story was no different from many other sad stories, but the impact was such that it left me physically distressed. Honestly, I think every story lodges itself somewhere in your brain. Sometimes a new experience touches what's already there, and occasionally that leads to a short circuit."
By: Margot Krijnen (text), Philip Driessen (photography)