MEDICOLEGALMEDICOLEGALASPECT OF ASPECT OF

ER PRACTICEER PRACTICE

PREPARED BYPREPARED BYABU GHARBIEH MAZEN, MD.ABU GHARBIEH MAZEN, MD.EMERGENCY DEPARTMENTEMERGENCY DEPARTMENT

MAKASSED HOSPITALMAKASSED HOSPITALJERUSALEMJERUSALEM

•Palestinian laws Palestinian laws •Standard medicalStandard medical practicespractices

patientspatients

the statethe state

ERER•PhysicianPhysician•health care providers health care providers

ObligateObligate

Interface Interface within the context of the within the context of the legal and justice systems legal and justice systems

ACTACT

CASES WITHCASES WITHLEGAL ASPECTSLEGAL ASPECTS

ASSAULT &ASSAULT &INJURIESINJURIES POISONINGPOISONING

What should ER healthWhat should ER healthCare providers know ?Care providers know ?

Their dutiesTheir duties Rights of the Rights of the patientpatient

Duties of Physician & health care providers Duties of Physician & health care providers in ERin ER

Awareness of legal obligations.Awareness of legal obligations. Recognize patterns of injury.Recognize patterns of injury.

Documentation of Observations. Documentation of Observations.

Processing evidences.Processing evidences. History and data collection: patient & witnesses.History and data collection: patient & witnesses.

Documentation of physical examination.Documentation of physical examination.

Using diagnostic and documentary tools.Using diagnostic and documentary tools.

Documentation of the injury by photography.Documentation of the injury by photography.

Case reporting: to state social services or law Case reporting: to state social services or law enforcement agencies.enforcement agencies.

Death declaration. Death declaration.

RIGHTS OF THE PATIENT’S RIGHTS OF THE PATIENT’S 1.1. Respectful care. Respectful care.

2.2. To know, by name, the physician responsible for coordinating To know, by name, the physician responsible for coordinating his or her care. his or her care.

3.3. To obtain from his or her physician complete current To obtain from his or her physician complete current information about diagnosis, treatment, and prognosis in information about diagnosis, treatment, and prognosis in easily understandable terms. easily understandable terms.

4.4. To receive from his or her physician information necessary to To receive from his or her physician information necessary to give informed consent prior to the start of any procedure or give informed consent prior to the start of any procedure or treatment. Except in emergencies.treatment. Except in emergencies.

5.5. To refuse treatment to the extent permitted by law. To refuse treatment to the extent permitted by law.

6.6. To be transferred to another facility, providing the transfer is To be transferred to another facility, providing the transfer is medically permissible, and the facility has agreed to accept medically permissible, and the facility has agreed to accept the patient. the patient.

7.7. To expect that medical information, will be communicated to To expect that medical information, will be communicated to the referring physician. the referring physician.

8.8. To privacy concerning the medical care program. Case To privacy concerning the medical care program. Case discussion, consultation, examination, and treatment are discussion, consultation, examination, and treatment are confidential and will be conducted discreetly. confidential and will be conducted discreetly.

9.9. The patient has the right to know in advance what The patient has the right to know in advance what appointment times and physicians are available and where to appointment times and physicians are available and where to go for continuity of care provided by the Clinic. go for continuity of care provided by the Clinic.

Cases to be reportedCases to be reported

1.1. Child and elderly abuse. Child and elderly abuse. 2.2. Domestic violence.Domestic violence.3.3. Suicidal cases.Suicidal cases.4.4. Gun shot injuries. Gun shot injuries. 5.5. Rape.Rape.6.6. Illegal pregnancy. Illegal pregnancy. 7.7. MVA.MVA.8.8. Infectious diseases:Infectious diseases:

AIDS.AIDS. TB.TB. Meningitis.Meningitis. Cholera etcCholera etc..

9.9. Drug and narcotic abuse.Drug and narcotic abuse.10.10. Mammals bite mainly rabies prone.Mammals bite mainly rabies prone.11.11. Unexplained death for any age. Unexplained death for any age.

PATTERNS PATTERNS OF INJURYOF INJURY

Mode of Mode of productionproduction circumstancescircumstances

HomicidalHomicidal AccidentalAccidental

SuicidalSuicidal

missilemissile heatheat

sharp forcesharp force

blunt forceblunt force

chemicalschemicals

electricityelectricity

componentscomponents

1.1. AbrasionAbrasion2.2. Bruise (ecchym)Bruise (ecchym)3.3. ContusionContusion4.4. Laceration/tearLaceration/tear5.5. Stab/cutStab/cut6.6. BiteBite7.7. BurnBurn8.8. Missile Missile penetrationpenetration9. Strangulation9. Strangulation

Wound Description

Entrance woundsEntrance wounds Exit woundsExit wounds

11 Circular, oval, or Circular, oval, or triangulartriangular

Longitudinal Longitudinal

22 Circumferential rim of Circumferential rim of abrasionabrasion

Do not sustain friction Do not sustain friction damagedamage

33 Presence of gunpowderPresence of gunpowder Absent Absent

44 Minimal bleedingMinimal bleeding Large amount of bleedingLarge amount of bleeding

55 Smaller in sizeSmaller in size Larger in sizeLarger in size

MISSILE PENETRATING WOUNDS

Physicians without forensic training should avoid giving any Physicians without forensic training should avoid giving any opinion regarding a wound being an entrance or exit.opinion regarding a wound being an entrance or exit.

Identification of the site of the entrance and exit of a gunshot Identification of the site of the entrance and exit of a gunshot wound path is an important step in the reconstruction of the wound path is an important step in the reconstruction of the shooting incident.shooting incident.

Clothing soiled with gunpowder residue must be protected Clothing soiled with gunpowder residue must be protected and retained for collection by law-enforcement agencies for and retained for collection by law-enforcement agencies for analysis in the crime lab. analysis in the crime lab.

HISTORY EVALUATIONHISTORY EVALUATION

TOXIC TOXIC INGESTIONINGESTION

NON – TOXIC NON – TOXIC INGESTIONINGESTION

REASONREASONTIMETIME

SUBSTANCE/SSUBSTANCE/S

AVAILABILITYAVAILABILITY

QUANTITYQUANTITYROUTROUT

POISONING

S/S & S/S & TOXODROMESTOXODROMES

LOCATIONHome/work

MEDICAL RECORDS MEDICAL RECORDS

1.1. Confidential. Confidential.

2.2. Subject of a legal proceedings.Subject of a legal proceedings.

3.3. Central part of the court deliberations. Central part of the court deliberations.

4.4. Testimony from the physician that created that record.Testimony from the physician that created that record.

5.5. Cross-examine by the defendant or the accused.Cross-examine by the defendant or the accused.

6.6. Physicians must recognize the legal responsibility Physicians must recognize the legal responsibility that society places on them and be prepared to that society places on them and be prepared to provide competent, professional testimony when provide competent, professional testimony when required.required.

6.6. Should contains proper documentation & information. Should contains proper documentation & information.

6.6. make the record more representative > use tools and make the record more representative > use tools and photos etc. photos etc.

What do my medical records contain?What do my medical records contain?

Patient medical history (mainly patient’s own words). Patient medical history (mainly patient’s own words). Family’s medical history. Family’s medical history. Lab test results. Lab test results. Prescribed medications. Prescribed medications. Details of patient’s lifestyle (which can include Details of patient’s lifestyle (which can include

smoking, high risk sports and alcohol and drug use). smoking, high risk sports and alcohol and drug use).

Who holds and gives access to records?Who holds and gives access to records?

GPs. GPs. Hospitals. Hospitals. Social Workers. Social Workers. Courts.Courts. Law enforcing agencies. Law enforcing agencies.

Who can see patient’s medical records?Who can see patient’s medical records?

Patient. Patient.

Anyone who has patient’s written permission. Anyone who has patient’s written permission.

Patient’s parent or guardian if they are under 16. Patient’s parent or guardian if they are under 16.

A representative appointed by a court. A representative appointed by a court.

After patient’s death >> his personal representative. After patient’s death >> his personal representative.

PRESERVATION AND COLLECTION OF EVIDENCEPRESERVATION AND COLLECTION OF EVIDENCE

extremely valuable.extremely valuable.

Protocol > consultation with the local law– enforcement agency. Protocol > consultation with the local law– enforcement agency.

The use of a simple envelope that enables a physician to: The use of a simple envelope that enables a physician to:

Identify the patient. Identify the patient. The date the evidence was recovered.The date the evidence was recovered. Where it was recovered from.Where it was recovered from. And to whom it was given. And to whom it was given. Signed and sealed by the physician for its protection. Signed and sealed by the physician for its protection. Use of an appropriate receipt form documenting the transfer Use of an appropriate receipt form documenting the transfer

of this evidence.of this evidence.

Evidences to be collected and preservedEvidences to be collected and preserved

1.1. Weapons ( bullets, knifes etc ).Weapons ( bullets, knifes etc ).

2.2. Wounds particles ( gun shot powder ).Wounds particles ( gun shot powder ).

3.3. Clothing.Clothing.

4.4. Blood and other body materials. Blood and other body materials. (evidence of sexual assault).

5.5. Gastric content.Gastric content.

6.6. Poisons and medications. Poisons and medications.

7.7. Photographs.Photographs.

8.8. X – rays.X – rays.

9.9. Notes & consultations.Notes & consultations.

REPORT OF DEATHREPORT OF DEATH

An important responsibilityAn important responsibility of the emergency physicians. of the emergency physicians.

Notification:Notification: local law-enforcement agency & attorney general. local law-enforcement agency & attorney general.

Case identification:Case identification: those require an investigation those require an investigation of the of the

circumstances of the deathcircumstances of the death..

Determination:Determination: whether an autopsy is necessary or not. whether an autopsy is necessary or not.

Such deaths are generally those:Such deaths are generally those: individuals who die suddenly while not under theindividuals who die suddenly while not under the

immediate care of a physician. immediate care of a physician.

any death associated with some type of injury.any death associated with some type of injury.

suspicious or unusual death. suspicious or unusual death.

It should be emphasized that: It should be emphasized that:

Are not a factor in determining whether the death should be reported Are not a factor in determining whether the death should be reported to the law authority.to the law authority.

1.1. the length of time a patient has been in hospital the length of time a patient has been in hospital 2.2. the age of an injury associated with the underlying cause of deaththe age of an injury associated with the underlying cause of death

Legal aspect of CPRLegal aspect of CPR

Rescuers are Rescuers are VolunteersVolunteers

(Good samaritan)(Good samaritan)

Rescuers areRescuers areProfessionalsProfessionals

CPR is part of their jobCPR is part of their job

Protected Protected Not protectedNot protected(Gross mistakes)(Gross mistakes)

CPR: WHEN TO STOP IT ?CPR: WHEN TO STOP IT ?

1.1. The victim's breathing & heart beats begin on their The victim's breathing & heart beats begin on their own.own.

2.2. Until other rescuers take over your effort. Until other rescuers take over your effort.

3.3. Until you are exhausted & unable to continue Until you are exhausted & unable to continue ..

4.4. Obvious signs of death are apparent. Obvious signs of death are apparent.

5. A medical professional tells you to stop.5. A medical professional tells you to stop.

When not to start CPRWhen not to start CPR

Obvious signs of death:Obvious signs of death: Dependent livido: black, blue or reddish discoloration of black, blue or reddish discoloration of

the skin.the skin. Rigor mortis: rigidity. rigidity. Algo mortis: low temperature. low temperature. Injuries that are incompatible with life. that are incompatible with life.

Threats to rescuers safety.Threats to rescuers safety.

Valid order of DNR ???.Valid order of DNR ???.