DEPARTMENT OF ACCIDENT & EMERGENCY GURU TEG BAHADUR HOSPITAL, DELHI

DEPARTMENT OF ACCIDENT & EMERGENCYGURU TEG BAHADUR HOSPITAL, DELHI

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INTRODUCTION

EMERGENCY MEDICAL CARE

It involves diagnosis of disease state

and degree of emergency in a short

time coupled with an accurate

judgment and treatment

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THE EMERGENCY AND CASUALTY

• We are frequently involved in assessment and treatment of patients who may be either victims of violence or accidents or having medical situations with some legal implications

• We are desired to have adequate knowledge and training in the forensic aspects of medical care

• Otherwise necessary and significant evidence can be overlooked, lost, inadvertently discarded, or its admissibility denied, ultimately resulting in failure to establish and fix responsibility for the case in accordance with the law of the land

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SCOPE

ALL THOSE INVOLVED WITH THE PATIENTS ARE SUPPOSED TO FOLLOW THE LAWS OF THE STATE

• We must know our responsibilities towards patient, state & law

• Ignorance of law is not an excuse

• Knowledge of relevant acts & laws is very important and desirableExamples: the CPA Act, the MTP Act, the PNDT Act, the Transplantation of Human Organs Act, the Mental Health Act, the Registration of Births & Deaths Act, the Motor Vehicles Act, the NDPS Act, the Drugs & Cosmetics Act, the Protection of Human Rights Act)

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INJURY: DEFINITIONS

INJURY• Any harm, whatever illegally caused to any person in

body, mind, reputation or property (Sec.44, IPC)

ASSAULT• An offer or threat or attempt to apply force to body of

another in a hostile manner (Sec.351, IPC)

MECHANICAL INJURY (WOUND)• A break of the natural continuity of any of the tissues

of the living body, produced by physical violence

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INJURIES:LEGAL CLASSIFICATION

SIMPLE INJURY• An injury which is not grievous is simple

GRIEVOUS INJURY• According to Sec.320, IPC, any of the following injuries is

grievous: • Emasculation• Permanent privation of sight of either eye• Permanent privation of hearing of either ear• Privation of any member or joint• Destruction or permanent impairing of the power of any member

or joint• Permanent disfigurement of the head or face• Fracture or dislocation of a bone or tooth• Any hurt which endangers life or which causes the victim to be in

severe bodily pain, or unable to follow his ordinary pursuits for a period of 20 days

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INJURIES:MEDICAL CLASSIFICATION

I. MECHANICAL INJURIES1. Abrasion

2. Contusion (Bruise)

3. Laceration

4. Incised wound

5. Stab (Punctured) wound

6. Firearm wound

7. Fracture and Dislocation

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INJURIES:MEDICAL CLASSIFICATION

II. THERMAL INJURIES1. Due to cold: Frostbite; Trench foot;

Immersion foot 2. Due to heat: Burns; Scalds

III. CHEMICAL INJURIES1. Corrosive acid 2. Corrosive alkali

IV. OTHERSDue to electricity, lightning, X-

rays, radioactive substance etc

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EXAMINATION OF PATIENTSIN EMERGENCY & CASUALTY

PURPOSES

1.To assess the patient’s suffering and give appropriate treatment

2.To prepare a report for:

• Medical purposes

• Medicolegal purposes: Personal injury

claim; Public liability; Work-cover;

Medical negligence

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EXAMINATION OF PATIENTSIN EMERGENCY & CASUALTY

AIMS

• To determine nature and extent of illness

• To assess causation of illness/injury

• To give prompt and appropriate treatment

• To determine level of impairment

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RECEIVING APATIENT IN EMERGENCY

THREE WAYS

1. Patient presents on his/her own or brought by the relatives/attendants

2. Patients/accused is brought by the police or referred by a court for examination and reporting

3. Patients is referred from other doctor or hospital

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TYPES OF CASES RECEIVEDIN EMERGENCY AND CASUALTY

• Brought-in Dead• Medical Emergencies• Surgical Emergencies• Trauma Cases: assault, roadside accident,

factory accident, firearm injury, burns injury• Poisonings• Sexual Offence, criminal abortion• Cases referred from courts or otherwise for

age estimation

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WHO IS AMEDICOLEGAL CASE

NO STRICT DEFINITION

1. After history taking and thorough examination, if the doctor feels that the circumstances/ findings of the case have legal implications

2. The case is brought by the police or referred by a court for examination and reporting

3. The case was already attended to by a doctor and an MLC was registered in the previous hospital, and now he/she is referred for further management/ advice

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IMPORTANT DUTIES INMEDICOLEGAL CASES

• Inform the police

• After taking consent, examination the patient and give treatment

• Do medicolegal formalities and issue medicolegal certificate as early as possible

• In serious cases, arrange for recording the dying declaration: VERY IMPORTANT

• Don’t accede to request by the patient or the persons accompanying, not to register an MLC. Use your own judgment and experience

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CONFIDENTIALITY

• Confidentiality must be maintained in all cases and we must keep secret all information regarding the patient that is come across during the course of the examination

• Medicolegal reports should be handed over to the authorized police official only, after getting them duly received on the carbon copy of the same

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TRIAGE

• Prioritizing patients into categories based on their severity of illness/ injury, likelihood of survival and urgency of medical care

• The goal is to identify high-risk patients who would benefit from the resources available

• In Emergency Room, we are the first responders for triage

• Assessment must be made quickly and treatment started

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RESUSCITATE THE PATIENTFIRST

• The cases may be brought conscious, unconsciousness or dead

• In the casualty, while attending to a patient, we should understand that our first priority is to save the life of the patient

• Supreme Court ruling: “medicolegal aspects are secondary to life of patient”

• While attending to an emergency, we should do everything possible to resuscitate the patient and ensure that he/she is out of danger

• ALL LEGAL FORMALITIES STAND SUSPENDED TILL THIS IS ACHIEVED

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RESUSCITATION INEMERGENCY MEDICAL CARE

• Some specific measures in resuscitation andemergency medical care include:

• CPR• Mechanical ventilation• Oxygen support & nebulizations• IV fluids & blood transfusions• Gastric lavage• Oral & injectable medications (for pain,

vomiting, breathlessness, allergic reactions, high-grade fever etc)

• Specific antidotes• Wound cleaning & dressings• Limb splintage & immobilization• Certain emergency/ life-saving procedures

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STEPS OFTHE EXAMINATION

• CONSENT

• Should always be taken while examining and treating a patient

• Whenever a doctor agrees to treat a patient there is a doctor patient contract (Implied Consent) to treat a patient with reasonable care & skill

• For examination there is an implied consent. But for more than examination and to be valid, the consent must be competent, freely given, informed, expressed and specific to the procedure being performed

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CONSENT IN AMEDICOLEGAL CASE

• In medicolegal cases, an informed consent includes information that:

1. The examination to be conducted would be a medicolegal one and would culminate in the preparation of a medicolegal injury report,

2. All relevant investigations needed for the said purpose would be done, and

3. The findings of the report may go against the patient if they do not tally with the history given (very important)

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CONSENT IN AMEDICOLEGAL CASE

“However, a person arrested as accused in a

criminal offence may be medically examined

without his/her consent on the request of a

police officer (of a rank of Sub-Inspector or

higher) or on the orders of the court, if there

are sufficient grounds to believe that such

examination will provide evidence of the

commission of the offence”

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• In case of examination of a woman

• It is preferable that a lady doctor should examine her, or, wherever this is not possible, a female disinterested attendant (a nurse, for example) should be present during the examination

• However, in case of a woman who is an alleged victim of sexual offence, only a lady doctor can examine her

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• HISTORY

• Quickly establish impartiality and gain the patient’s confidence

• Establish chronology of events accurately

• Distinguish clearly between history obtained from others and that stated by the patient

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• CLINICAL EXAMINATION

• Start gently and explain every move

• Assess the mental status

• Record the vitals (pulse, BP etc)

• Perform the clinical examination methodically and thoroughly

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• Examine the injuries adequately, observe the movements carefully, and assess the impairments (if any) diligently

• Be over-conscious of respecting privacy while undressing

• Record findings as they are

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• Comment on inconsistencies (if any) between the history given and the findings of clinical examination

• Tactics to expose malingering are not unwarranted

• Ultimately an objective assessment of injury/ impairment is made

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INVESTIGATION OF WOUND CHARACTERISTICS

• The investigation of undiagnosed trauma often begins with the evaluation of wound pattern characteristics

• Detailed documentation of the appearance of the wound may be the identifying factor in determining the type of weapon used to inflict the injury

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INVESTIGATION OF WOUND CHARACTERISTICS

• The documentation should include the location of the injury, exact measurements and other characteristics of bruises, abrasions, cuts, lacerations, stab wounds and entry/exit wounds

• Diagrams, body maps or photography are helpful in reconstructing injury patterns in subsequent investigations or at autopsy

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MECHANICAL INJURIES:SOME DETAILS

• ABRASION

• Destruction of the skin, which usually involves the superficial layers of the epidermis only

• Four types: Scratch, Graze, Pressure abrasion, Impact abrasion

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• ABRASION

Age of abrasion can be estimated only roughly:

• Fresh: bright red• 12-24 hours: bright scab• 2-3 days: reddish-brown scab• 4-7 days: epithelial covering the

defect under the scab• After 7 days: scab dies & falls

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• CONTUSION (BRUISE)

• An effusion of blood into the tissues, due to the rupture of blood vessels, caused by blunt trauma

• Seen as a reddish-purple swelling of skin that does not blanch when pressed upon

• Fresh contusion is usually tender & slightly raised

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• CONTUSION (BRUISE)

When a contusion fades, its colour changes characteristically over the time as the body metabolizes the blood cells in the skin:

• Fresh: red• Few hours to 3 days: blue• 4 days: bluish-black to brown• 5-6 days: greenish• 7-12 days: yellow• 2 weeks: normal

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• INCISED WOUND

• Clean cut through the tissue, which is longer than its depth

• Characters: Margins; Width; Length; Shape; Haemorrhage; Direction; Beveling

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• INCISED WOUND

Age of an uncomplicated incised wound can be estimated from its healing pattern:

• Fresh: haematoma formation• 12 hours: red swollen & adherent edges • 24 hours: continuous layer of

endothelium covered by scab of dry clot• 36 hours: capillary network complete• 48-72 hours: connective tissue• 3-5 days: vessel-thickening &

obliteration• 1-2 weeks: Scar formation

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• STAB (PUNCTURED) WOUND

• Injury caused by sharp-pointed object, penetrating the skin and underlying tissues, which is deeper than its length & width on skin

• May be penetrating or perforating (through-and-through) wound

• Characters: Margins; Length; Depth; Shape; Direction

• The wound of entry is larger with inverted edges and the wound of exit is smaller with everted edges

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• LACERATION• Tear or split of skin, mucous membrane,

muscle or internal organ produce by application of blunt force to broad area of the body, which crushed or stretched the tissue beyond its limit of elasticity

• Four types: Split laceration; Stretch laceration; Avulsion; Tear; Cut laceration

• Characters: Margins; Edges; Bruising; Shape; Dimensions (length, breadth & depth); Haemorrhage; Others (hair bulb, bone, foreign body)

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• FIREARM WOUND

• Wound caused by a firearm (any instrument which discharges a projectile by the expansive force of the gases produced by burning of an explosive substance)

• May be caused by a rifled weapon (rifle, pistol, revolver, machine gun etc) or a smooth-bored weapon/ shotgun (single barrel, double barrel, slide-action, bolt-action, semi-automatic, automatic etc)

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• FIREARM WOUND (Contd…)• Characters of a firearm wound depend on:

the distance from which the weapon is discharged (contact wound, close-range wound, long-range wound); the size of the shot; the nature of the explosive; and the type of firearm

• Special Characters: Entry wound; Abrasion collar; Contusion collar; Beveling of skull plate; Exit wound; Atypical patterns (due to tail wobble, yawning bullet, tumbling bullet, silencers, weapon defects, Ricochet bullet, bullet graze, unusual number of entry/exit wounds, tandem bullet etc)

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• FIREARM WOUND (Contd…)

• Distance from which a firearm weapon was discharged and other important relevant information can be arrived at from the characteristics of the wounds coupled with other evidences

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• FRACTURE

• Breakage in the continuity of a bone or tooth

• Types: Fissured fracture; Depressed fracture; Comminuted fracture; Pond fracture; Gutter fracture; Ring fracture; Perforating fracture; Sutural fracture etc

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• DISLOCATION• Displacement of a bone or tooth from

its normal joint/socket

• SPRAIN• Injury to the ligament

• STRAIN• Injury to the muscle

• AMPUTATION• Removal of a body extremity

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• HEAD INJURY

• Fracture

• Concussion: Brain injury caused by a blow, without any penetration into the skull or brain, leading to a state of temporary unconsciousness

• Intracranial hemorrhage: EDH; SDH; SAH; ICH

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• OTHER REGIONAL INJURIES

• Spinal injury

• Intra-thoracic injury

• Intra-abdominal injury

• Neuro-vascular injury

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• BURN

• A lesion caused by application of heat or chemical substances to the external or internal surfaces of the body, which causes destruction of tissues

• Degree of burn: Epidermal; Dermo-epidermal; Deep

• Characters: Site; Degree; Extent (“rule of nine”)

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• SCALD

• Injury resulting from the application of liquid above 60ºC or from steam

• Shows soddening & bleaching but do not singe the hair and do not blacken or char the skin

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• ELECTRICAL INJURY

• Injury caused by contact with electrical conductors

• Systemic and local effects depend upon the kind, amount and path of the current and the site of injury

• Joule burn is specific and diagnostic of contact with electricity and is found at the point of entry of the current

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• ASPHYXIAL INJURIES

• Hanging• Strangulation• Smothering• Drowning

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• SEXUAL OFFENCES

• Natural offences: Rape; Incest

• Unnatural offences: Sodomy; Tribadism; Bestiality; Buccal coitus

• Sexual perversions

• CRIMINAL ABORTIONS

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WADDELL SIGNS(1980)

• Superficial or non-anatomic tenderness. Pain doesn’t correspond to a known structure

• Simulation. Axial loading or rotation• Distraction. Straight leg raise while sitting• Regional sensory change or weakness. Whole

limb weakness• Over-reaction. Theatrical response to gentle

examination

• Comments: Increased in the elderly, therefore not recommended; Presence does not imply the absence of organic pathology or true pain; 3 or more required for significance

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MARKS OF IDENTIFICATION

• MUST BE NOTED IN AN MLC

• Ideally two scar marks should be noted

• Otherwise thumb impression should be taken (Male-Lt, Female-Rt, Infant-Foot)

• Witnessed signatures of the patient can help in identification

• All the entries should be made promptly and correctly

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PRESERVATION OF EVIDENCE IN AN MLC

• Hospital emergency departments are regularly required to be in contact with essential evidence in criminal cases

• Trace and physical evidences are very important and useful to establish the facts of a crime

• Recognize the importance of recovering possible items of evidence in a legally acceptable manner in case of an MLC

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• The most common types of evidence are clothing, bullets, bloodstains, hairs, fibres, and small pieces of material such as fragments of metal, glass, paint, and wood

• Appropriate specimens / samples (such as blood, urine, semen, saliva, gastric aspirate, vaginal swab, hair, nail etc) should also be taken from the patient wherever required

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• Collection and preservation of medicolegal evidence should be done with proper labeling and sealing under the doctor's supervision

• Documentation must reflect the accurate identification, description, and security of medicolegal evidence

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• The samples should be handed over to the police official concerned, along with the medicolegal report and a proper requisition letter detailing the tests to be conducted on such samples

• If the samples have been collected on the request of the police, the fact is to be mentioned in the report and no requisition is necessary

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STEPS IN SPECIFIC CASES

• IN INJURY CASE


• After taking consent, do the medicolegal examination and give treatment

• Keep injuries under observation, if necessary, and issue medicolegal certificate as early as possible. After observation, send supplementary report as early as possible

• Arrange for recording dying declaration, if necessary

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• IN BURNS CASE


• If patient is serious, arrange for recording dying declaration


• Issue medicolegal certificate and send report as early as possible

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• IN POISONING CASE• Inform the police


• Record the symptoms & signs carefully

• If patient is serious, arrange for recording dying declaration

• Samples of gastric lavage, vomitus, urine, blood should be preserved, sealed, labeled and sent to police under proper receipt


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• IN RAPE CASE



• Samples for examination of blood, stains, semen, swabs, sweat, hair, nails etc should be preserved, sealed, labeled and sent to police under proper receipt


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• IN RAPE CASE

THE CrPC 2005 AMENDMENT:

Some mandatory points for examination:

• Must examine within 24 hrs after taking proper consent

• Always examine in presence of female

• Note the time of start and the time of end

• Always state reasons for all conclusions

• It is necessary to keep samples for examination of blood, stains, semen, swabs, sweat, hair, nails, DNA etc as required

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PREPARATION OFMEDICOLEGAL REPORT

• Medicolegal report (MLR) should be prepared immediately after the examination of a medicolegal case is done

• It should be prepared in duplicate, preferably with a ball-point-pen, in a clear and legible handwriting

• Cutting/ overwriting etc should be avoided as much as possible and all corrections should be properly initialed

• Abbreviations of any sort should be avoided

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DYING DECLARATION

• It is a statement by a person who is conscious and knows that death is imminent concerning what he or she believes to be the cause or circumstances of death that can be introduced into evidence during a trial in certain cases

• It should be got recorded in all serious medicolegal cases

• It is better to get it recorded from magistrate. In case a delay is likely, the doctor should himself record dying declaration

• Doctor should certify compos mentis in both the situations

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IN CASE OF DEATHOF A MEDICOLEGAL CASE

• Do not issue death certificate or hand over the dead body to the relatives of the deceased

• Inform the police immediately

• Send the body to the hospital mortuary for preservation

• Request a medicolegal postmortem examination

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IN CASE OF DEATHOF A MEDICOLEGAL CASE

• After the inquest is conducted, postmortem examination should be performed by an authorized doctor

• After the legal formalities are completed, the dead body is released to the lawful heirs by the police

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A SUMMARY OF THEROLES & RESPONSIBILITIES

The Examining Doctor in the Emergency and Casualty should:

1. Triage patients at risk for forensic injuries and give prompt and adequate medical treatment

2. Follow appropriate medicolegal guidelines and protocols in compliance with accreditation standards

3. Do proper documentation and preservation of evidence

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A SUMMARY OF THEROLES & RESPONSIBILITIES

Contd…..

4. Secure evidence and maintain the chain of custody

5. Report all MLCs to proper legal agencies

6. Serve as liaison between the health care institutions and the law enforcement agencies

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TAKE HOME MESSAGE

• Methodical examination, prompt treatment, proper documentation and timely information are all that are necessary and desirable while examining patients in Emergency and Casualty

• The best way is to understand the situation clearly, analyze it thoroughly, and then act appropriately

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Thank YouThank You

Documents

DEPARTMENT OF ACCIDENT & EMERGENCY GURU TEG BAHADUR HOSPITAL, DELHI