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)

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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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 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. Abrasion
2. Contusion (Bruise)
3. Laceration
4. Incised wound
5. Stab (Punctured) wound
6. Firearm wound
7. Fracture and Dislocation

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

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 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

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 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

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 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
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 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
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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 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

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 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)
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 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”

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 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

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 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

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 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
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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 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

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 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
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 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
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 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
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 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

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 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
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 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 (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 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, bolt-
action, semi-automatic, automatic etc)

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 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)
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 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

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 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
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 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
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 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
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 MECHANICAL INJURIES:
SOME DETAILS
• OTHER REGIONAL INJURIES

• Spinal injury

• Intra-thoracic injury

• Intra-abdominal injury

• Neuro-vascular injury

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 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; Dermo-

epidermal; Deep

• Characters: Site; Degree; Extent (“rule of

nine”)
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 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

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 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
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 MECHANICAL INJURIES:
SOME DETAILS
• ASPHYXIAL INJURIES
• Hanging
• Strangulation
• Smothering
• Drowning

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 MECHANICAL INJURIES:
SOME 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
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

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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

66
Thank You

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