AMIUT

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EXAMINATION OF PATIENTS IN ACCIDENT AND EMERGENCY
DEPARTMENT OF ACCIDENT EMERGENCY GURU 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 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)

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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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INJURIESLEGAL 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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INJURIESMEDICAL CLASSIFICATION

• I. MECHANICAL INJURIES
• Abrasion
• Contusion (Bruise)
• Laceration
• Incised wound
• Stab (Punctured) wound
• Firearm wound
• Fracture and Dislocation

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INJURIESMEDICAL CLASSIFICATION

• II. THERMAL INJURIES
• Due to cold Frostbite Trench foot Immersion
  foot
• Due to heat Burns Scalds
• III. CHEMICAL INJURIES
• Corrosive acid
• Corrosive alkali
• IV. OTHERS
• Due to electricity, lightning, X-rays,
  radioactive substance etc

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EXAMINATION OF PATIENTSIN EMERGENCY CASUALTY

• PURPOSES
• To assess the patients suffering and give
  appropriate treatment
• 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
• Patient presents on his/her own or brought by the
  relatives/attendants
• Patients/accused is brought by the police or
  referred by a court for examination and reporting
  
• 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
• After history taking and thorough examination, if
  the doctor feels that the circumstances/ findings
  of the case have legal implications
• The case is brought by the police or referred by
  a court for examination and reporting
• 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
• Dont 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 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

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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
• The examination to be conducted would be a
  medicolegal one and would culminate in the
  preparation of a medicolegal injury report,
• All relevant investigations needed for the said
  purpose would be done, and
• 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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STEPS OFTHE 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

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STEPS OFTHE EXAMINATION

• HISTORY
• Quickly establish impartiality and gain the
  patients confidence
• Establish chronology of events accurately
• Distinguish clearly between history obtained from
  others and that stated by the patient

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STEPS OFTHE 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

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STEPS OFTHE 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

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STEPS OFTHE 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

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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 INJURIESSOME 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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MECHANICAL INJURIESSOME 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

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MECHANICAL INJURIESSOME 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

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MECHANICAL INJURIESSOME 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

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MECHANICAL INJURIESSOME DETAILS

• 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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MECHANICAL INJURIESSOME 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

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MECHANICAL INJURIESSOME 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
  (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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MECHANICAL INJURIESSOME 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)

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MECHANICAL INJURIESSOME 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, bolt-action, semi-automatic,
  automatic etc)

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MECHANICAL INJURIESSOME 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)

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MECHANICAL INJURIESSOME 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

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MECHANICAL INJURIESSOME 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

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MECHANICAL INJURIESSOME 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

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MECHANICAL INJURIESSOME 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

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MECHANICAL INJURIESSOME DETAILS

• OTHER REGIONAL INJURIES
• Spinal injury
• Intra-thoracic injury
• Intra-abdominal injury
• Neuro-vascular injury

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MECHANICAL INJURIESSOME 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 Dermo-epidermal Deep
• Characters Site Degree Extent (rule of nine)

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MECHANICAL INJURIESSOME 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

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MECHANICAL INJURIESSOME 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

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MECHANICAL INJURIESSOME DETAILS

• ASPHYXIAL INJURIES
• Hanging
• Strangulation
• Smothering
• Drowning

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MECHANICAL INJURIESSOME DETAILS

• 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
  doesnt 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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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

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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

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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

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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

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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

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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

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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

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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

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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
• Triage patients at risk for forensic injuries and
  give prompt and adequate medical treatment
• Follow appropriate medicolegal guidelines and
  protocols in compliance with accreditation
  standards
• Do proper documentation and preservation of
  evidence

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A SUMMARY OF THEROLES RESPONSIBILITIES

• Contd..
• Secure evidence and maintain the chain of custody
• Report all MLCs to proper legal agencies
• 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 You