060209L - TRAUMATIC INJURY: ETHICO-LEGAL and SOCIAL ISSUES

By Professor Omar Hasan Kasule Sr.

1.0 CAUSES, TYPES, AND PATHOPHYSIOLOGY

1.1 CAUSES OF TRAUMATIC INJURY:

Traumatic injury can occur on a mass scale such as in military conflicts or natural disasters or can occur on a more limited scale to individuals or groups of individuals in the community or the workplace. Injuries may be intentional or non-intentional. The intentional ones may be criminal aggression against another person, self harm due to mental problems, or attempted suicide. The unintentional are usually called accidents but this term is not accurate. The final event like a car crash may appear accidental but it has intentional antecedents like driving recklessly at a high speed.

1.2 TYPES OF TRAUMATIC INJURY:

Traumatic injury can be classifieD as blunt injury, penetrating injury, burns (thermal, chemical, electrical), and bites (animal and human). In practice, several of these injuries occur at the same time in the same individual. For examples car accidents, an increasing cause of injury, can cause blunt injury to the head, penetrating abdominal injury, and even burns.

1.3 MANIFESTATIONS OF TRAUMATIC INJURY:

Trauma to the skin is in the form of lacerations, abrasions, open wounds, and contusions. Trauma to the chest can manifest as flail chest due to fracture of ribs, open pneumothorax, tension pneumothorax (due to air leakage into the pleural cavity), hemothorax, cardiac tamponade, and aortic rupture. Trauma to the abdomen manifests as hemoperitoneum, penetrating wounds, as well as blunt injury. Trauma to CNS can result into coma and spinal injuries. Burns can be thermal, chemical, or electric. Primary degree involves only the epidermis. Secondary degree involves the dermis. Third degree involves all the skin and subcutaneous fat.

1.4 PATHOPHYSIOLOGY OF TRAUMATIC INJURY

The Pathophysiologic response to injury can manifest in any of the following ways: metabolic derangement, cardio-respiratory failure and shock, coagulopathy, multi-organ dysfunction syndrome, and neuropathophysiology. The body always attempts to repair traumatic injury through the process of wound healing (primary and secondary) which proceeds in three stages: inflammatory phase, proliferation phase, and maturation phase.

2.0 ETHICO-LEGAL ISSUES IN EMERGENCY CARE

CONSENT TO EXAMINATION and TREATMENT

2.1 Conscious patient:

In cases of traumatic injury requiring urgent medical care we should try as much as possible to respect the patient’s autonomy. Even in emergencies some informed consent should be obtained from conscious patients before examination and treatment. For some injuries there may be time to discuss with the patient and this should be respected. Competent adults can refuse treatment even if it means death. However attempts should be made to ascertain competence because such refusal indicates lack of understanding or incompetence because of the stressful conditions. In normal circumsances a normal competent person would not refuse life-saving examination and treatment. If incompetence is proved then treatment can be given despite patient objections. Refusal by conscious competent patients may be logical like fear of infection or may be illogical like racist refusal of blood transfusion because of dislike of blood from another race. In either case the patient’s wishes are respected. If a conscious patent refuses treatment then we just do maintenance while discussing capacity and competence.

2.2 Unconscious patient:

For an unconscious urgent decisions are taken without consent unless there is a previous objection in the form of a living will. Treatment in this case is based on the overriding purpose of protecting life, hifdh al nafs. These proxy decisions can be taken by the nearest relatives, persons designated by the patient in advance or attending medical personnel. However proxy decisions to refuse reasonable treatment cannot generally be accepted because they are not in the patient’s best interests. Exceptions are cases of very risky treatments, new treatments, or if there is fear of serious side effects like infections.

2.3 Patients without competence:

Decisions of treatment for children and mentally incapacitated patients are taken by the nearest relatives or in their absence by the attending physicians. The overriding considerations in all of these is the best interest of the patient which is preserving life.

2.4 Forensic examinations:

There are emergency interventions not in the patient’s interests like forensic tests to prove that the patient committed a crime such as taking alcohol or drugs. Other forensic interventions are in the patient’s interests like examination of a rape victim to obtain evidence against the assailant. In either case informed consent is needed unless the examinations are carried out by police surgeons under specific legislative authorization. Storing specimens for possible use later in criminal investigations without the patient’s consent may be illegal unless there is a specific court order or enabling legislation.

2.5 Self-harm and suicide

Injury to oneself or to others is illegal even if the victim requested it and consented to it. Suicide, attempted suicide, self-mutilation, and sadomasochism are all illegal. Persons who attempt suicide may refuse treatment because they wanted to die. Fortunately many arrive at hospital already incapacitated and treatment has to be given without consent. Significant links exist between life stresses and mental illness on one hand with suicide on the other hand. This implies that those who attempt suicide do not have complete competence because they are not acting voluntarily. Suicide notes are written during the stress of suicide and cannot be respected as advance directive not to treat. This is held even if the note includes a refusal of resuscitation. Many who commit suicide do so to escape, to punish, or to draw attention and may not be aware of the finality of death. We cannot allow them to kill themselves by refusing treatment. The life does not belong to them. They are just custodians of life; all life belongs to God who gives it and takes it away. Proxy decisions by relatives not to treat victims of suicide attempts are not respected.

3.0 CONFIDENTIALITY and DISCLOSURE

3.1 Conscious patient

Confidentiality must be maintained in emergency situations like other medical encounters. If the patient is conscious and is competent, his/her consent must be obtained before sharing any confidential information with the family. Information may be disclosed without the patient’s consent in the public interest for example confirmation of diagnosis of a contagious disease that is of public health importance.

3.2 Unconscious patient

If the patient is unconscious, general but not specific information can be shared by the family. More specific information may however be shared with the family about an unconscious patient for purposes of obtaining proxy consent, harvesting organs for transplantation, or use of tissues for research. Information may also be disclosed in the public interest. In such a case the personal identity of the patient should be protected as much as possible.

3.3 Disclosure to the police

Any information disclosure to the police must be done with the patient’s consent. If the patient is inconscious then only information in the public interest may be disclosed. Disclosure to the police can also be done if there is a court order to that effect.

3.4 Notifiable diseases

Doctors examining and treating patients in emergency rooms are required by law to notify health authorities of notifiable infectious diseases, occupational injuries, deaths, major injuries, and abortions.

3.5 Domestic violence and child abuse

Good and detailed records of injuries due to domestic violence and child abuse should be made in preparation for future litigation. Disclosure to authorities should follow local guidelines. Cases of genital mutilation are considered child abuse and should be reported according to local guidelines.

4.0 OTHER ISSUES IN EMERGENCY CARE

4.1 Family attendance at resuscitation

The family can be allowed to attend resuscitation procedures if their presence will not interfere with technical procedures. This will give them an opportunity to have a last-minute contact with the deceased that has a lot of psychological benefits.

4.2 Triage in the emergency room

In an emergency situation with many needy patients, a system of triage is needed to separate and prioritize the more severe from the less severe cases for more immediate attention. Ethical issues of justice and fair play could appear of there is subtle discrimination based on age, gender, socio-economic status, or race/ethnicity.

4.3 Overstepping professional boundaries in an emergency

Overstepping professional boundaries is a necessity in an emergency situation to save life. This could take the form of a nursing doing a doctor’s job or a doctor undertaking a procedure he does not carry out routinely. The justification is the overriding concern to save life and the realization that if nothing were done the patient would die anyway.

4.4 A doctor at an accident site

Doctors may find themselves at accident sites without the equipment and facilities needed to do a good job. These samaritan doctors are required to give as much as assistance as is expected and of which they are capable. They should desist from doing heroic measures because they will be liable in case of any injury to the patient. It should be noted that a good samaritan doctor at an accident site is not obliged by the law to intervene since there is no contract between him and the patient. His intervention is a good act.

5.0 RELIGIOUS and SOCIAL DUTIES

5.1 Acts of worship, ‘ibadat

The Law under the principle of hardship provides for the injured by simplifying acts of worship for them. A patient with injury and incapable of making wudhu on his own could have another one pour water for him. If there is a wound that prevents use of water, you can rub with wet fingers on the bandage. Wiping on leather socks or on ordinary socks is undertaken in case of wounds preventing used of water. If water cannot be used at all tayammum is undertaken. Tayamum can be carried out instead of wudhu for patients with burns. Physical movements of salat are restricted for those with disabilities; they pray in the most comfortable position that they can manage.

5.2 Marriage, munakahaat:

Impotence in paraplegia can be grounds for nullification of marriage if the wife requests. Disabled husbands who can no longer work to support the family may have the marriage nullified at the request of the wife.

5,3 Business transactions, buyuu’u:

Employment of the disabled must consider their limited performance.

5.4 Activities of daily living, aadaat

The physically disabled have special problems in feeding and drinking.

EXERCISES: TRUE/FALSE QUESTIONS

1. The following statements are true about traumatic injury

A. It is allowed to wash a patient in ablution if he cannot use his hands

B. Tayammum is preferred for cases of profuse or active bleeding at sites of wudhu

C. In cases of wounds, a wet hand is rubbed on the bandage during wudhu

D. Tayammum is carried out instead of ghusl in cases of burns

E. Patients with physical disabilities offer salat in the most comfortable position