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DEPARTMENT OF ACCIDENT & EMERGENCY GURU TEG BAHADUR HOSPITAL, DELHI 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 2 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 3 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 desirable Examples: 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) 4 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 5 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 6 INJURIES: MEDICAL CLASSIFICATION I. MECHANICAL INJURIES 1. 2. 3. 4. 5. 6. 7. Abrasion Contusion (Bruise) Laceration Incised wound Stab (Punctured) wound Firearm wound Fracture and Dislocation 7 INJURIES: MEDICAL CLASSIFICATION II. THERMAL INJURIES 1. 2. Due to cold: Frostbite; Trench foot; Immersion foot Due to heat: Burns; Scalds III. CHEMICAL INJURIES 1. 2. Corrosive acid Corrosive alkali IV. OTHERS Due to electricity, lightning, X-rays, radioactive substance etc 8 EXAMINATION OF PATIENTS IN 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 9 EXAMINATION OF PATIENTS IN 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 10 RECEIVING A PATIENT 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 11 TYPES OF CASES RECEIVED IN 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 12 WHO IS A MEDICOLEGAL 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 13 IMPORTANT DUTIES IN MEDICOLEGAL 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 14 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 15 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 16 RESUSCITATE THE PATIENT FIRST • 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 17 RESUSCITATION IN EMERGENCY MEDICAL CARE • Some specific measures in resuscitation and emergency 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 18 STEPS OF THE 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 19 CONSENT IN A MEDICOLEGAL 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) 20 CONSENT IN A MEDICOLEGAL 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” 21 STEPS OF THE EXAMINATION • 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 22 STEPS OF THE EXAMINATION • 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 23 STEPS OF THE EXAMINATION • 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 24 STEPS OF THE EXAMINATION • CLINICAL EXAMINATION • 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 25 STEPS OF THE EXAMINATION • CLINICAL EXAMINATION • 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 26 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 27 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 28 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 29 MECHANICAL INJURIES: SOME DETAILS • 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 30 MECHANICAL INJURIES: SOME DETAILS • 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 31 MECHANICAL INJURIES: SOME DETAILS • 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 32 MECHANICAL INJURIES: SOME DETAILS • INCISED WOUND • Clean cut through the tissue, which is longer than its depth • Characters: Margins; Width; Length; Shape; Haemorrhage; Direction; Beveling 33 MECHANICAL INJURIES: SOME DETAILS • 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 34 MECHANICAL INJURIES: SOME DETAILS • 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 (throughand-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 35 MECHANICAL INJURIES: SOME DETAILS • 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) 36 MECHANICAL INJURIES: SOME DETAILS • 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, boltaction, semi-automatic, automatic etc) 37 MECHANICAL INJURIES: SOME DETAILS • 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) 38 MECHANICAL INJURIES: SOME DETAILS • 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 39 MECHANICAL INJURIES: SOME DETAILS • 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 40 MECHANICAL INJURIES: SOME DETAILS • • • • 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 41 MECHANICAL INJURIES: SOME DETAILS • 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 42 MECHANICAL INJURIES: SOME DETAILS • OTHER REGIONAL INJURIES • Spinal injury • Intra-thoracic injury • Intra-abdominal injury • Neuro-vascular injury 43 MECHANICAL INJURIES: SOME DETAILS • 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; Dermoepidermal; Deep • Characters: Site; Degree; Extent (“rule of nine”) 44 MECHANICAL INJURIES: SOME DETAILS • 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 45 MECHANICAL INJURIES: SOME DETAILS • 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 46 MECHANICAL INJURIES: SOME DETAILS • ASPHYXIAL INJURIES • • • • Hanging Strangulation Smothering Drowning 47 MECHANICAL INJURIES: SOME DETAILS • SEXUAL OFFENCES • Natural offences: Rape; Incest • Unnatural offences: Sodomy; Tribadism; Bestiality; Buccal coitus • Sexual perversions • CRIMINAL ABORTIONS 48 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 49 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 50 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 51 PRESERVATION OF EVIDENCE IN AN MLC • 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 52 PRESERVATION OF EVIDENCE IN AN MLC • 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 53 PRESERVATION OF EVIDENCE IN AN MLC • 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 54 STEPS IN SPECIFIC CASES • IN INJURY CASE • Inform the police • 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 55 STEPS IN SPECIFIC CASES • IN BURNS CASE • Inform the police • If patient is serious, arrange for recording dying declaration • After taking consent, do the medicolegal examination and give treatment • Issue medicolegal certificate and send report as early as possible 56 STEPS IN SPECIFIC CASES • IN POISONING CASE • Inform the police • After taking consent, do the medicolegal examination and give treatment • 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 • Issue medicolegal certificate and send report as early as possible 57 STEPS IN SPECIFIC CASES • IN RAPE CASE • Inform the police • After taking consent, do the medicolegal examination and give treatment • Samples for examination of blood, stains, semen, swabs, sweat, hair, nails etc should be preserved, sealed, labeled and sent to police under proper receipt • Issue medicolegal certificate and send report as early as possible 58 STEPS IN SPECIFIC CASES • 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 59 PREPARATION OF MEDICOLEGAL 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 60 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 61 IN CASE OF DEATH OF 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 62 IN CASE OF DEATH OF 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 63 A SUMMARY OF THE ROLES & 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 64 A SUMMARY OF THE ROLES & 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 65 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 66 Thank You 67