CHAPTER 4 MEDICOLEGAL DUTIES IN CASUALTY SERVICE (GENERAL) Prof. B.B.L.

Aggarwal In medicolegal sense, Casualty Department and its services are the most important part of a hospital. It is generally observed that the less experienced doctors deal with most important department where cases of casualties from traffic or other accidents, of catastrophies such as fires, explosion, collapsed building and similar incidents, victim of poisoning comatosed patients with or without head injuries, victims of heart disease and all sorts of emergencies are brought round the clock. Many such cases are medicolegal in nature and duties/ responsibilities in these cases are two fold :1. Medical care 2. Legal responsibilities

Medical Care :I. Round the Clock Service :- Since the important and serious cases may be brought to casualty at any time, medical care should be provided round the clock. The patients should never be turned away, until the medical officer has seen and examined them. Depending upon the seriousness of illness or injury, the patient should be admitted or referred to some other section/hospital or asked to go home. The junior staff should take the advice of more senior colleagues where there is slightest doubt about the proper course of action. There should be provision for observation beds so that the cases of head injuries or other injuries which appear to be trivial on external examination may be kept for observation till cleared from serious internal injuries. II. Staff Space and emergency resuscitation measures :- The medical emergency department should be provided with sufficient qualified and experienced staff (Medical, paramedical) and others), space, equipment/ apparatuses (resuscitation) and life saving drugs, x-ray and emergency laboratory facilities. Senior doctor should be incharge and there should be adequate nursing and other staff. Consultant in different branches should be available to assist the Casualty Medical Officer by giving their opinion whenever required. Intravenous glucose saline and other intravenous fluids, plasma blood etc. should be available immediately in case they are needed at short notice. All the resuscitation apparatuses should be in working order. III. Prophylactic Measures, First Aid and Prevention of adverse Reaction :Prophylactic measures should be taken immediately to combat the disease. There should be no delay in providing the first-aid to the patient. Arrangements for stomach wash and antidotes to all common poisons including anti-snake venom should be available and be given immediately whenever required. Treatment gets priority over medicolegal formalities specially when the condition of the patient is serious. Grave responsibility falls upon the person prescribing or administering drug if an adverse reaction takes place and therefore, efforts should be made to prevent this reaction. It is a serious problem because it can occur suddenly, unexpectedly with a deadly outcome. Drug allergy/ antibiotic allergy patients should be identified by taking an adequate history. If the patient had an allergic reaction to a drug in the past and if a positive history comes, the drug should not be given unless it is lifesaving and no alternative drug can be administered. Failure to do a skin test for a drug generally considered to cause allergic reaction may make a physician liable if an adverse reaction taken place.

This is true even through there was no previous history of allergic reaction by the drug. One should keep in mind that an adverse reaction may occur even during testing and therefore, the doctor should be ready to deal with such an emergency. In these cases immediate intervention is mandatory as it is acute medical emergency. Generally these reactions are overcome by giving vasopressor agents and maintaining an adequate airway. Drugs like epinephrine, aminophyline injectable antihistamines and oxygen etc. should be available and given whenever required. For maintenance of cardiac and respiratory function, external cardiac massage and mouth to mouth resuscitation may be necessary. However, if unfortunately a person dies due to anaphylactic reaction empty ampule/ vial or the drug should be preserved and its expiry and manufacturing date, name of manufacturer, batch number etc. should be noted. The matter should be immediately reported to police and the dead body should not be handed over to relatives unless legal formalities are completed. IV Stomach Wash: For removal of unabsorbed poison gastric lavage should be done at an earliest opportunity anytime within 3-4 hours after its ingestion. A stomach tube is used for this purpose. It is a flexible rubber tube about one and half meter long and 1 cm. in diameter. A glass funnel is attached at its one end and the other end is blunt and rounded with large holes near the tip, through which fluid poured in may enter the stomach and the contents of a stomach are early siphoned out. The tube has a mark at 50cm. from the blunt and rounded end and when the tube is passed upto this mark, it suggests that the stomach has been reached. This end is lubricated with glycerine or any other suitable lubricant material. Gastric lavage should be done while patient is lying on his left side or prone with head hanging over the edge of the bed supported by an assistant. The lubricated end of the tube is passed by slowly depressing the tongue with a depressor. The funnel of the stomach tube is held above the head of the patient and half a litre of plain water is poured into the stomach through it. The funnel is then lowered below the level of the stomach and as a result of this, the contents of the stomach are siphoned in clean bowl. This is preserved for chemical analysis. Afterwards, half a litre of water containing a suitable antidote is poured down the funnel and the stomach is washed as before. The stomach wash is repeated till the fluid coming out of the stomach is of the same colour as that of the fluid poured in. This indicated that there is no interaction between the antidote and the poison and that is has been neutralized. However, a small quantity of fluid containing the antidote is left in the stomach in order to neutralize whatever small quantity of poison is left. The stomach wash is contradicted in comatose patients because of danger of going the fluid into respiratory passages. It is not done in poisoning by strong corrosives like mineral acids and concentrated alkalies because of danger of perforation of stomach or oesophagus by the tube. It is also not done in patients having convulsions. The convulsions are first controlled by suitable anaesthetising agents and then the gastric lavage is done.. The contradictions for the use of stomach tubes can be broadly summarized as follows, starting with word c :1. 2. 3. 4. corrosive (i.e. mineral acids and alkalies) Coma Convulsions Children (Ryles tube or a tube of narrow caliber is used in children)

Legal Responsibilities :- Legal responsibilities will be discussed here in general as already there are separate articles on specific subjects like Examination of injured person, victims in sexual offences and accused in sex crimes, certification of drunkenness, age etc. one should keep in mind that a lady should be present at the time of medical examination of all female cases and generally the medicolegal

examination is carried out after taking the written consent of the patient, the age for which is 12 years. Consent of guardian/parents should be taken if the patient is below 12 years. Left thumb impression in cases of males/females and right thumb impression in cases of females should be taken on the report. This would also signify that the person has been examined and he cannot deny that he was not examined. For the convenience, these responsibilities are dealt under the following headings:A Identification, registration & isolation of a Medicolegal case

Medicolegal case is a case of injury or ailment etc., in which investigation by law enforcing agencies are essential to fix the responsibility regarding the causation of said injury or ailment. No difficulty arises in registration of these cases when it is brought by the police. The difficulty arises when the person injured or sick comes himself or brought by his relatives who try to conceal the facts due to one or the other motive. In such cases, the attending doctor after taking history and clinical examination of the patient in the casualty, should try to identify a Medicolegal case and register it. All medicolegal cases should be routed through casualty and the necessary entries made in medicolegal register. Following category of case can be labeled as medicolegal : 1. Cases of injuries and burns the circumstances of which suggest commission of an offence by some one. 2. All Vehicular, factory or other unnatural accident cases specially when there is likelihood of patients death or grievous hurt. 3. Cases of suspected or evident sexual assault. 4. Cases of suspected or evident criminal abortion. 5. Cases of unconsciousness where its cause is not natural or not clear. 6. All cases of suspected or evident poisoning/intoxication. 7. Cases referred from court or otherwise for age estimation etc. 8. Cases brought dead with improper history creating suspicion of an offence. 9. Any other case not falling under the above categories but has legal implication. The above mentioned cases whether brought by police or some one else must be labeled as medicolegal even if they have been brought several days after the incident. A fresh medicolegal report may not be prepared if the case brought, had been registered medicolegal at some other hospital. Request of the patient or the accompanying relative or friend for not registering the case as medicolegal, should not be acceded. The medicolegal cases should be isolated after the necessary registration. For isolation, a small medicolegal ward is ideal but if that is not possible then there should be separate beds for medicolegal cases with an attached card having M.L.C. word written in Red on its top. The card should have name, address and other details of the patient. B Notification to Police :-

In the casualty Department of a big hospital, a police official remains on duty round the clock and he should be informed in writing as and when a medicolegal case is registered or admitted. It is his duty to send the information to the police station concerned for necessary action. However, the police station should be directly informed by Casualty Medical Officer where a police official has not been put to duty in the casualty. In case of discharge or death of medicolegal case in the Casualty or in any other department of the hospital, the police should again be informed by Casualty Medical Officer in accordance with the above procedure. The information should also be given to police in all cases labeled as medicolegal. Close coordination and

cooperation between police authorities and the hospital doctors desired in respect of medicolegal cases. C Maintenance of records :-

It is necessary to maintain medical record for each person seen in Casualty department even if that patient is not formally admitted to the hospital. Not only such records are mandatory in the interest of adequate medical care but they may be called upon later for evidence in the court. Casualty Medical Officer must see that before a register of medicolegal report form is issued to the Casualty for use, it is properly numbered. A certificate regarding the number of forms in the said register be given by him on the first page of the register, Medicolegal document should be prepared in duplicate, preferably with a ball pen with utmost care on proper form/proforma giving all necessary details avoiding over writings. Corrections, if any, should be initialled and abbreviations avoided. Words should be distinct and legible and the report should be serially numbered. All entries including name, address of person, date and time of examination and its completion etc., should be mentioned as per the requirement in the form/proforma. Examination should be carried out in detail recording all the findings. Besides this, the general condition of the patient, state of consciousness, blood pressure, pulse, respiration, temperature, treatment given etc., should be recorded. Original copy should be handed over to police official concerned and the carbon copy be kept as official record. If the condition of the patient is serious and it is not possible to prepare a detailed medicolegal report in Casualty, it should be left for the doctor under whom the patient has been admitted. As pointed earlier, treatment in these cases takes precedence over medicolegal formalities. The Casualty Medical Officer in such cases should write only the general condition of patient and make a note that Detail examination and report be prepared later in the ward. The fact that the patient has been admitted or allowed to go after preliminary treatment must be mentioned in medicolegal report. All forms filled for x-Ray examination in medicolegal cases must bear M.L.C. word on the top so that necessary precautions could be taken by Radiology department in these cases. The X-Ray findings together with the number of X-Ray plates be recorded on the medicolegal report in order to facilitate further treatment and reference. The X-Ray report, and not the X-Ray films of these cases, should be handed over to police. In case the police officer wants some clarification/ subsequent opinion regarding any point in the report, an application in duplicate in this respect be obtained from him. The clarification/ subsequent opinion be given on the reverse of the application and a copy of the application and opinion be kept for and attached to the copy of original report prepared earlier. This would be helpful to medical officer for ready reference while appearing in Court at a later date. D. Custody of Medicolegal records :- Casualty Medical Officer must ensure proper custody of medicolegal records/ register etc., so that it is not tampered at any stage. It should be sent to Medical record section (Such department exists in big hospitals) or be kept separately in safe custody under lock and key when a register has been fully utilized. The medicolegal records should be produced in the court while appearing as a witness. A proper receipt should be obtained if the courts wants the XRay film or other document for their record. E. Preservation of other material/evidence:- This is one of the most important medicolegal duties as the material/evidence is required in invest in investigation of the case. Vaginal swab and public hairs in sexual offences and clothes in assault cases should be preserved packed and sealed. Foreign body, bullets, pellets, etc., if found on the person should be preserved in a packet, property labeled, the label having all the particulars of the case. In poisoning cases, excreta, stomach wash/vomitus etc., should

be preserved in clean stoppered bottles, which should be sealed and labeled correctly. Blood and urine samples in alcoholic intoxication, should be preserved in sodium fluoride and sodium citrate. A special M.L.C. seal should be used for sealing the medicolegal material. All such clothing/ articles etc., must be kept in safe custody under lock and key till they are handed over to the police authorities concerned. A proper receipt of such articles/ clothing must be obtained from the concerned police official as soon as they are handed over. F. Recording of Dying declaration :- It is the duty of the treating doctor to get the dying declaration recorded in those medicolegal cases where there is likelihood of death in near future. Normally dying declaration is recorded by a Magistrate and therefore, an immediate intimation should be sent to him by Medical Officer in writing for its recording. If the condition of patient is deteriorating and there is likelihood of death of patient before the arrival of Magistrate, the doctor should record the dying declaration himself/ herself in the presence of two respectable witnesses if the patient is mentally sound. These witnesses may be the fellow doctors or two persons from nursing staff or other respected person. The recording should be done in full details, in question and answer form in the vernacular (language) of words spoken by the person without any alterations. Suggestions or leading questions should always be avoided. The declaration should be free from outside prompting, assistance, compulsion or undue influence. After the statement is recorded, it should be read over to the dying declarant and his signature of thumb impression obtained at the bottom of the statement Signature of the respectable witness in whose presence, the declaration was recorded should also be obtained. Doctor would also put his own signatures to it. When the declarant writes down the statement himself, it should be countersigned and attested by the doctor and witness. While making the statement if a declarant becomes unconscious or dies the incomplete declaration should be signed by the doctor and witnesses mentioning the facts. Original as well as a carbon copy of dying declaration should be prepared. The original copy of declaration should be prepared. The original copy of declaration should be sent to concerned Magistrate in sealed cover and the carbon copy be attached with the case sheet of the case. If and when the Magistrate arrives to record a dying declaration, the concerned medical officer should help him and as far as possible be present during the recording of such declaration. A certificate of mental fitness of the case mentioning date and time must be given by Medical Officer and this should be entered in the records of the case. If a patient has been declared unfit, the reason thereof must be mentioned e.g. patient was declared not fit mentally to give a statement because of unconsciousness/ under effect of morphine or pethedine/ drugs etc., when Magistrate came to record a dying declaration on (date) at ..(time). G. Issuing of Medicolegal Certificate :- It is another legal duty of Casualty Medical Officer. Law required certificate whether it is an age certificate, certificate of drunkenness or injury report or report on cases of sexual assaults etc. These should be given immediately after the examination. H. Discharge of medicolegal Cases The person should not be allowed to leave without written instructions about the general care and specific after care in detail specially in cases of head injuries, sprains, muscle injury, abrasions and wound care. The police should be informed in writing well in advance about the tentative date and time of discharge of medicolegal case so that necessary and timely action can be taken by investigating agencies. I. disposal of cases who dies soon after their arrival or brought dead in the Casualty and Issuing of death certificate : - Cases where Casualty Medical Officer is very much satisfied after going through all available records, history and finds no evidence of a foul play, he may not label/ register it as medicolegal. However, it is

advisable to note all particulars in the casualty register including the name, address and relationship of the person who has brought the patient. The reason for not labeling such a case as Medicolegal should also be mentioned. If possible copies of the available relevant records be got made and preserved for future reference. Cases of un-natural death (accidents, burns, violence etc.) must be labeled medicolegal and all particulars be entered in the medicolegal register. As mentioned earlier, information of all such cases (brought dead or who died soon after arrival) labeled medicolegal should be sent to police officer concerned who would make arrangement for final disposal of the case after postmortem examination/ panchnama depending upon the circumstances. In such cases, death certificate form should be filled by the casualty medical officer and dead body is not to be handed over to the relatives. While preparing the death certificates, the doctor should write against the column of cause of death Not known-Brought dead. The medicolegal duties in the casualty service discussed above shall be helpful to doctors who deal with medicolegal cases in the casualty. If the above procedure is followed, many problems can be solved. It will be beneficial to the patients and society and the doctors would not cut sorry figures before investigating agencies or in law courts.