MEDICOLEGAL ASPECT OF ER PRACTICE PREPARED BY ABU GHARBIEH MAZEN, MD. EMERGENCY DEPARTMENT MAKASSED HOSPITAL JERUSALEM

Palestinian lawsPalestinian laws Standard medicalStandard medical practices practices patients the state ER PhysicianPhysician health care providershealth care providers Obligate Interface within the context of the legal and justice systems ACT

CASES WITH LEGAL ASPECTS ASSAULT & INJURIESPOISONING

What should ER health Care providers know ? Their duties Rights of the patient

Duties of Physician & health care providers in ER in ER  Awareness of legal obligations.  Recognize patterns of injury.  Documentation of Observations.  Processing evidences.  History and data collection: patient & witnesses.

 Documentation of physical examination.  Using diagnostic and documentary tools.  Documentation of the injury by photography.  Case reporting: to state social services or law enforcement agencies.  Death declaration.

RIGHTS OF THE PATIENT’S RIGHTS OF THE PATIENT’S 1.Respectful care. 2.To know, by name, the physician responsible for coordinating his or her care. 3.To obtain from his or her physician complete current information about diagnosis, treatment, and prognosis in easily understandable terms. 4.To receive from his or her physician information necessary to give informed consent prior to the start of any procedure or treatment. Except in emergencies. 5.To refuse treatment to the extent permitted by law.

6.To be transferred to another facility, providing the transfer is medically permissible, and the facility has agreed to accept the patient. 7.To expect that medical information, will be communicated to the referring physician. 8.To privacy concerning the medical care program. Case discussion, consultation, examination, and treatment are confidential and will be conducted discreetly. 9.The patient has the right to know in advance what appointment times and physicians are available and where to go for continuity of care provided by the Clinic.

Cases to be reported 1.Child and elderly abuse. 2.Domestic violence. 3.Suicidal cases. 4.Gun shot injuries. 5.Rape. 6.Illegal pregnancy. 7.MVA. 8.Infectious diseases:  AIDS.  TB.  Meningitis.  Cholera etc. 9.Drug and narcotic abuse. 10.Mammals bite mainly rabies prone. 11.Unexplained death for any age.

PATTERNS OF INJURY Mode of productioncircumstances HomicidalAccidental Suicidal missile missileheat sharp force blunt force chemicals electricity components 1.Abrasion 2.Bruise (ecchym) 3.Contusion 4.Laceration/tear 5.Stab/cut 6.Bite 7.Burn 8.Missile penetration penetration 9. Strangulation Wound Description

Entrance wounds Exit wounds 1 Circular, oval, or triangular Longitudinal 2 Circumferential rim of abrasion Do not sustain friction damage 3 Presence of gunpowder Absent 4 Minimal bleeding Large amount of bleeding 5 Smaller in size Larger in size MISSILE PENETRATING WOUNDS

 Physicians without forensic training should avoid giving any opinion regarding a wound being an entrance or exit.  Identification of the site of the entrance and exit of a gunshot wound path is an important step in the reconstruction of the shooting incident.  Clothing soiled with gunpowder residue must be protected and retained for collection by law-enforcement agencies for analysis in the crime lab.

HISTORY EVALUATION TOXICINGESTION NON – TOXIC INGESTION REASONTIME SUBSTANCE/S AVAILABILITY QUANTITYROUT POISONING S/S & TOXODROMES LOCATION Home/work

MEDICAL RECORDS MEDICAL RECORDS 1. Confidential. 2. Subject of a legal proceedings. 3. Central part of the court deliberations. 4. Testimony from the physician that created that record. 5. Cross-examine by the defendant or the accused. 6. 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. Should contains proper documentation & information. 6. make the record more representative > use tools and photos etc.

What do my medical records contain? What do my medical records contain?  Patient medical history (mainly patient’s own words).  Family’s medical history.  Lab test results.  Prescribed medications.  Details of patient’s lifestyle (which can include smoking, high risk sports and alcohol and drug use).

Who holds and gives access to records? Who holds and gives access to records?  GPs.  Hospitals.  Social Workers.  Courts.  Law enforcing agencies.

Who can see patient’s medical records? Who can see patient’s medical records?  Patient.  Anyone who has patient’s written permission.  Patient’s parent or guardian if they are under 16.  A representative appointed by a court.  After patient’s death >> his personal representative.

PRESERVATION AND COLLECTION OF EVIDENCE PRESERVATION AND COLLECTION OF EVIDENCE  extremely valuable.  Protocol > consultation with the local law– enforcement agency.  The use of a simple envelope that enables a physician to:  Identify the patient.  The date the evidence was recovered.  Where it was recovered from.  And to whom it was given.  Signed and sealed by the physician for its protection.  Use of an appropriate receipt form documenting the transfer of this evidence. of this evidence.

Evidences to be collected and preserved Evidences to be collected and preserved 1.Weapons ( bullets, knifes etc ). 2.Wounds particles ( gun shot powder ). 3.Clothing. 4.Blood and other body materials. 4.Blood and other body materials. (evidence of sexual assault). 5.Gastric content. 6.Poisons and medications. 7.Photographs. 8.X – rays. 9.Notes & consultations.

REPORT OF DEATH REPORT OF DEATH  An important responsibility of the emergency physicians.  Notification: local law-enforcement agency & attorney general.  Case identification: those require an investigation of the circumstances of the death. circumstances of the death.  Determination: whether an autopsy is necessary or not.

Such deaths are generally those: Such deaths are generally those:  individuals who die suddenly while not under the immediate care of a physician.  any death associated with some type of injury.  suspicious or unusual death.  It should be emphasized that: Are not a factor in determining whether the death should be reported to the law authority. 1. the length of time a patient has been in hospital 2. the age of an injury associated with the underlying cause of death

Legal aspect of CPR Rescuers are Volunteers (Good samaritan) Rescuers are Professionals CPR is part of their job Protected Not protected (Gross mistakes)

CPR: WHEN TO STOP IT ? CPR: WHEN TO STOP IT ? 1. The victim's breathing & heart beats begin on their own. 2. Until other rescuers take over your effort. 3. Until you are exhausted & unable to continue. 4. Obvious signs of death are apparent. 5. A medical professional tells you to stop.

When not to start CPR When not to start CPR  Obvious signs of death: black, blue or reddish discoloration of  Dependent livido: black, blue or reddish discoloration of the skin. the skin. rigidity.  Rigor mortis: rigidity. low temperature.  Algo mortis: low temperature. that are incompatible with life.  Injuries that are incompatible with life.  Threats to rescuers safety.  Valid order of DNR ???.