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Patient Information


Prerequisites of Medical Practice

A duly qualified medical professional, i.e. a doctor has a right to seek to practice medicine, surgery and dentistry by registering himself with the Medical Council of the State of which he is a resident, by following the procedure as prescribed under the Medical Act of the State.

The State Medical Council has the power to warn, refuse to register / remove from register the name of the doctor who has been sentenced by any court for any non-bailable offence or found to be guilty of infamous conduct in any professional respect. The State Medical Council has also the power to re-enter the name of the doctor in the register.

The provisions regarding offences and professional misconduct which may be brought before the appropriate Medical Council (State/Medical Council of India ) have been stated in the Code of Medical Ethics formulated by the Medical Council of India.

The appropriate Medical Councils are empowered to award such punishment as deemed necessary or direct the removal of the name of the delinquent registered practitioner from the register either permanently or for a specified period, if he has been found guilty of serious professional misconduct. No action against a medical practitioner can be taken unless an opportunity has been given to him to be heard in person or through an advocate.


Doctor - Patient Relationship

Since the ancient times, certain duties and responsibilities have been cast on persons who adopt the sacred profession as exemplified by Charak's Oath ( 1000 B.C.) and Hippocratic Oath ( 460 B.C.). In order to understand the complexities of the doctor-patient relationship it is necessary to know about the Duties and Obligations of a Doctor, Doctor-Patient contract and what constitutes Professional Negligence.

Duties and Obligations of a Doctor

Duties and obligations of doctors are enlisted in ordinary laws of the land and various Codes of Medical Ethics and Declarations - Indian and International, which are :
  1. Code of Medical Ethics of Medical Council of India.
  2. Hippocratic Oath.
  3. Declaration of Geneva.
  4. Declaration of Helsinki.
  5. International Code of Medical Ethics.
  6. Government of India Guidelines for Sterilization.
  7. Code of Medical Ethics of Medical Council of India.
These Codes and Declarations are being printed in the Appendices. On the basis of these various Codes of Ethics and Declarations, the duties can be summarised as under

Duties to Patient.

These are : Standard Care, Providing Information to the Patient /Attendant , Consent for Treatment, and Emergency Care.
(A) Standard Care
This means application of the principles of standard care which an average person takes while doing similar job in a similar situation :
  1. Due care and diligence of a prudent Doctor.
  2. Standard, suitable, equipment in good repair.
  3. Standard assistants : Where a senior doctor delegates a task to a junior doctor or paramedical staff, he must assure himself that the assistant is sufficiently competent and experienced to do the job, and fulfills the prescribed qualifications.
  4. Non-standard drug is a poison by definition.
  5. Standard procedure and indicated treatment and surgery.
  6. Standard premises, e.g. Nursing Home, Hospital , must comply with all laws applicable as imposed by the State and these must be registered wherever required.
  7. Standard proper reference to appropriate specialist.
  8. Standard proper record keeping for treatment given,surgery done, X-ray and pathological reports.
  9. Standard of not to experiment with patient ( SeeDeclaration of Helsinki in Appendix IV).
  10. Anticipation of standard risks of complications and preventive actions taken in time.
  11. Observe punctuality in consultation.
(B) Duty to provide information to patient / attendant
  1. Regarding necessity of treatment.
  2. Alternative modalities of treatment.
  3. Risks of pursuing the treatment, including inherent complications of drugs, investigations, procedure,surgery etc.
  4. Regarding duration of treatment.
  5. Regarding prognosis. Do not exaggerate nor minimizethe gravity of patient's condition.
  6. Regarding expenses and break-up thereof.
(C) Emergency Care
A doctor is bound to provide emergency care on humanitarian grounds, unless he is assured that others are willing and able to give such care. It may be noted that prior consent is not necessary for giving emergency / first-aid treatment. In emergency medico-legal cases, condition of first being seen by medical jurist is not essential.

Duties to Public.

  1. Health Education.
  2. Medical help when natural calamities like drought,flood, earth-quakes, etc. occur.
  3. Medical help during train accidents.
  4. Compulsory notification of births, deaths, infectious diseases, food poisoning etc.
  5. To help victims of house collapse, road accidents, fire,etc.

Duties towards Law Enforcers.

  1. To inform the police all cases of poisoning, burns,injury, illegal abortion, suicide, homicide,manslaughter, grievous hurt and its natural complications like tetanus, gas-gangrene , etc. This includes vehicular accidents, fractures, etc.
  2. To call a Magistrate for recording dying declaration.
  3. To inform about bride burning and battered child cases.

Duties not to violate Professional Ethics.

  1. Not to associate with unregistered medical practitioner and not allow him to practice what he is not qualified for.
  2. Not to indulge in self-advertisement except such as is expressly authorized by the M.C.I. Code of Medical Ethics.
  3. Not to issue false certificates and bills.
  4. Not to run a medical store / open shop for sale of medical and surgical instruments.
  5. Not to write secret formulations.
  6. Not to refuse professional service on grounds of religion, nationality, race,party politics or social status.
  7. Not to attend patient when under the effect of alcohol.
  8. No fee sharing ( Dichotomy).
  9. Not to talk loose about colleagues.
  10. Information given by patient /attendant to be kept as secret. Not to be divulged to employer, insurance company, parents of major son/daughter without consent of patient. Even in court this information is given only if ordered by the Court.
  11. Recovering any money ( in cash or kind) in connection with services rendered to a patient other than a proper professional fee, even with the knowledge of the patient.

Duties not to do anything illegal or hide illegal acts.

  1. Perform illegal abortions / sterilization's.
  2. Issue death certificates where cause of death is not known.
  3. Not informing police a case of accident, burns,poisoning, suicide, grievous hurt, gas gangrene.
  4. Not calling Magistrate for recording dying declaration.
  5. Unauthorized, unnecessary , uninformed treatment and surgery or procedure.
  6. Sex determination (in certain States).

Duties to each other.

  1. A doctor must give to his teachers respect and gratitude.
  2. A doctor ought to behave to his colleagues as he would like them to behave to him.
  3. A doctor must not entice patients from his colleagues,even when he has been called as a specialist.
  4. When a patient is referred to another doctor, a statement of the case should be given. The second doctor should communicate his opinion in writing /over telephone/fax direct to the first doctor.
  5. Differences of opinion should not be divulged in public.
  6. A doctor must observe the principles enunciated in 'The Declaration of Geneva' approved by the World Medical Association.

Duties of the Patient / Attendant

When a patient ( consumer ) hires or avails of services of a doctor for treatment, he has the following duties :-
  1. He must disclose all information that may be necessary for proper diagnosis and treatment.
  2. He must co-operate with the doctor for any relevant investigations required to diagnose and treat him.
  3. He must carry out all the instructions as regards drugs,food, rest, exercise or any other relevant /necessary aspect.
  4. In the case of a private medical practitioner he must compensate the doctor in terms of money and money alone. Moral considerations apart, failure on the part of the patient / attendant to do his duty : (

  5. a) will enable the doctor to terminate patient -physician contract and that would free him from his legal responsibilities,
    b) will be construed as contributory negligence, and weaken the case of the patient for compensation.

Doctor - Patient Contract

Contract is defined as an agreement between two or more persons which creates an obligation to do or not to do a particular thing. Contract may be implied or express.

An implied contract is one inferred from conduct of parties and arises where one person renders services under circumstances indicating that he expects to be paid therefor, and the other person knowing such circumstances, avails himself of benefit of those services.

An express contract is an actual agreement of the parties, the terms of which are openly uttered or declared at the time of making it, being stated in distinct and explicit language, either orally (oral agreement ) or in writing (written agreement).

The doctor-patient contract is almost always of the implied type, except where a written informed consent is obtained.

While a doctor cannot be forced to treat any person, he has certain possibilities for those whom he accepts as patients.It is an implied contract. Implied contract is not established when :
  1. The doctor renders first-aid in an emergency ;
  2. He makes a pre-employment medical examination for a prospective employer ;
  3. He performs an examination for life insurance purpose ;
  4. He is appointed by the trial court to examine the accused for any reason ; and
  5. when he makes an examination at the request of an attorney for last suit purposes.A doctor-patient contract requires that the doctor must :
    1. continue to treat such a person ;
    2. with reasonable care ;
    3. reasonable skill ;
    4. not undertake any procedure/ treatment beyond his skill and
    5. must not divulge professional secrets.
I) Continue to Treat - Responsibility towards a patient begins the moment a doctor agrees to examine the case. He must not, therefore, abandon his patient except under the following circumstances -
  1. The patient has recovered from the illness, for which treatment was initiated.
  2. The patient / attendant does not pay the doctor's fees (in case of a private practitioner).
  3. The patient / attendant consults another doctor ( of any branch of medicine ) without the knowledge of the first attending doctor.
  4. The patient / attendants do not co-operate and follow the doctor's instructions.
  5. The patient is under some other responsible care, e.g., the patient, after admission in a hospital, comes under care of senior doctors / unit head.
  6. The doctor has given due notice (orally or written ) for discontinuing treatment.
  7. The doctor is convinced that the illness is a fictious one.
II) Reasonable Care - A doctor must use clean and proper instruments, and provide his patients with proper and suitable medicines if he dispenses them himself. If not, he should write the prescriptions legibly,using standard abbreviations and mention instructions for the pharmacist in full. He should give full directions to his patients as regards administration of drugs and other measures,preferably in local written language. He must suggest / insist on consultation with a specialist in the following circumstances :
  1. When the case is complicated.
  2. When the question arises about performing an operation which may be dangerous to life or requiring amputation.
  3. Operating on a case in which there has been a criminal assault.
  4. Performing an operation which may affect the intellectual or reproductive functions of a patient.
  5. In cases where there is suspicion of poisoning or other criminal act.
  6. When desired by the patient / attendants.
  7. When it appears that the quality of medical service is required to be enhanced.
  8. When there is no one from whom informed consent can be obtained.
III) Reasonable Skill - The degree of skill a doctor undertakes is the average degree of skill possessed by his professional brethren of the same standing as himself. The best form of treatment may differ when different choices are available. There is an implied contract between the doctor and the patient when the patient is told in effect : "Medicine is not an exact science. I shall use my experience and best judgement and you take the risk that I may be wrong. I guarantee nothing."

IV) Not to undertake any procedure beyond his skill - This depends upon his qualifications, special training and experience. The doctor must always ensure that he is reasonably skilled before undertaking any special procedure / treating a complicated case. To quote an example, a doctor who is not sufficiently trained or qualified should not administer anaesthesia.

V) Professional Secrets - A professional secret is one which a doctor comes to learn in confidence from his patients, on examination, investigations or which is noticed in the ordinary privacies of domestic life. A doctor is under a moral and legal obligation not to divulge any such secret except under certain circumstances. This is known as privileged communication which is defined as a communication made by a doctor to a proper authority who has corresponding legal, social and moral duties to protect the public. In must be bonafide and without malice, e.g., as a witness in a court of law; warning partners or spouses of AIDS patients and those found infected with HIV; informing public health authorities of food poisoning from a hotel etc; assisting apprehension of a person who has committed a serious crime ;informing law enforcers about medico-legal cases, etc.

Professional Negligence ( Malpractice, Malpraxis)

Professional negligence is defined as the breach of a duty caused by the omission to do something which a reasonable man guided by those considerations which ordinarily regulate the conduct of human affairs would do or doing something which a prudent and reasonable man would not do.

Medical negligence or malpractice is defined as lack of reasonable care and skill or wilful negligence on the part of a doctor in the treatment of a patient whereby the health or life of a patient is endangered.

The term 'damage' means physical, mental or functional injury to the patient, while 'damages ' are assessed in terms of money by the court on the basis of loss of concurrent and future earnings, treatment costs, reduction in quality of life ,etc.

In order to achieve success in an action for negligence, the consumer must be able to establish to the satisfaction of the court that :
  1. the doctor (defendant) owed him a duty to conform to a particular standard of professional conduct ;
  2. the doctor was derelict and breached that duty ;
  3. the patient suffered actual damage ; and
  4. the doctor's conduct was the direct or proximate cause of the damage.
The burden of establishing all four elements is upon the patient / consumer. Failure to provide substantiative evidence on any one element may result in no compensation.

Criminal Negligence.

Here the negligence is so great as to go beyond matter of mere compensation. Not only has the doctor made a wrong diagnosis and treatment, but also that he has shown such gross ignorance, gross carelessness or gross neglect for the life and safety of the patient that a criminal charge is brought against him. For this he may be prosecuted in a criminal court for having caused injury to or the death of his patient by a rash and negligent act amounting to culpable homicide under Section 304-A of the Indian Penal Code. Some examples are as follows :
  1. Injecting anesthetic in fatal dosage or in wrong tissues.
  2. Amputation of wrong finger, operation on wrong limb,removal of wrong organ, or errors in ligation of ducts.
  3. Operation on wrong patient.
  4. Leaving instruments or sponges inside the part of body operated upon.
  5. Leaving tourniquets too long, resulting in gangrene.
  6. Transfusing wrong blood.
  7. Applying too tight plaster or splints which may cause gangrene or paralysis.
  8. Performing a criminal abortion.

What is a trauma cenre?

Care of the injured patient has been fundamental to the practice of medicine since recorded history. The word 'trauma' is derived from the Greek meaning 'bodily injury'. The Greek word iatros (healer) was originally found in Homer's Iliad and referred as the 'remover of arrows'. The first trauma centres were used to care for wounded soldiers in Napoleon's armies.

The lessons learned in successive military conflicts have advanced our knowledge of care of the injured patient. Wars established the importance of minimising time from injury to definitive care. The extension of this concept to the management of civilian trauma led to the evolution of today's trauma systems. Incidence of trauma is on the rise globally due to industrialisation, urbanisation, increase in mechanised transport, urban violence, social conflicts, and man-made as well as natural disasters. Trauma is a number one killer below 40 years leading to high morbidity, mortality, disability and economic loss to the country.

If current trend continues, road traffic injuries intentional injuries i.e. self inflicted injuries, interpersonal violence and war related injuries will rank among the 15 leading causes of death and burden of disease. Road traffic injuries is a leading cause of death by injury accounting for 20.3 per cent of all deaths from injury.

It is 10th leading cause of all deaths, ninth leading contributor to the burden of disease world wide. Deaths from injuries are projected to rise from 5.1 million at present to 8.4 million by 2020. In India, 80, 000 persons got killed and 38 million persons got injured due to road traffic accidents. In Armed Forces, approximately 20 persons per 1000 population get admitted in the hospitals due to non-enemy action injuries per year.

In a system, the hospital which provides acute care for the severely injured patients (trauma centre) is a key component of a system which encompass all phases of care from pre-hospital through acute care and rehabilitation.

The trauma system should be fully integrated into the emergency medical service system and should strive to meet the needs of all injured patients requiring an acute care facility, regardless of severity of injury, geographic location, or population density. The goal is to match a facility's resources with a patient's needs so that optimal and cost effective care is achieved.

Structure of a trauma care system involves
  1. Administrative components
    1. Leadership
    2. System development
    3. Legislation
    4. Finances
  2. Operational and clinical components
    1. Injury prevention and control
    2. Human resources
    3. Pre hospital care
  3. Ambulance service
  4. Communication system
  5. Definitive care facilities
  6. Trauma care facility
  7. Interfacility transfer
  8. Rehabilitation
  9. Information systems
  10. Evaluation
  11. Research

Trauma Centre

Trauma centre is defined as a specialised hospital facility distinguished by the immediate availability of specialised surgeons, physician specialists, anaesthesiologists, nurses, and resuscitation and life support equipment on a 24-hour basis to care for severely injured patients or those at risk for severe injury. Trauma centre have been identified to have four levels as per the resource availability and level I trauma centre has been defined by American College of Surgeons as follows: -
  1. Regional resource trauma centre that has the capability of providing leadership and total care for every aspect of injury from prevention through rehabilitation.
  2. Can be a lead hospital also.
  3. A tertiary care facility.
  4. Capability - at least 1200 trauma patients yearly.
  5. Twenty four hour in-house availability of surgeon in emergency department.

Planning parameters for trauma centre

Location

It should be located on ground floor and should have direct access from main road. A separate approach, other than the OPD with a spacious parking area for cars and two-wheelers is required. It should be located adjacent to the OPD to share the resources such as diagnostics and also pool resources in case of a disaster.

It should be well lighted and boldly signposted both for day and night, direction signs should be put on the main traffic routes passing through the station (If happens to be the only trauma service in the station). Drive through and covered ambulance post should be capable of accommodating at least two ambulances.

Helipad is required for major trauma centres and in rural, hilly, or unapproachable areas. Good and well maintained lawn with fixed benches and seasonal flowers serves as an additional waiting area for relatives.

Inter-relationship

A trauma centre should have close inter-relationship with operation theatre, radiology, blood bank, laboratory, ICU, obstetrics, records, OPD and mortuary. Some authorities recommend close relationship with CCU as well. Many sub departments are required in trauma centre itself i.e. OT, diagnostics etc.

Work & traffic flow

Efficiency of any busy and high intensity department like trauma centre can be greatly increased by smooth and orderly flow of traffic for
  1. Patient
  2. Staff
  3. Supplies
Internal traffic flow should aim at maximising efficiency at all times. All modalities of communication be employed to save time such as telephone, intercom etc.

Entrance

Entrance should be separate from main hospital's entrance and separate for ambulant and stretcher bound patients which includes a ramp. Doors of entrance should be 2.4 metre wide, 2-way with glass panel at eye height and spring to keep them in open position and they should open into the reception area. Automatic sliding doors also can be used to prevent accidents in case of swinging doors. The entrance to registration should be at a close distance.

Reception Area

Entrance should open into a large open space with reception desk in front. Trolley, stretcher, and wheelchair parking area as well as a facility for cleaning stained trolleys are a must. Waiting room for patients and relatives, police desk room, room for driver's, space for medico-social worker, cafeteria, toilets, registration and records, security, cash counter, and telephone booth should open into reception.

Other areas recommended are puja room, grief room, flower, chemist, and bookshop. Size of reception area depends on patient load, (0.75 sqm per patient for 1/3rd of attending population in waiting area). BIS recommends 1.75 sqm per hospital bed for reception area.

Waiting Area

Waiting area is required for ambulant patients and accompanying family members. It is also for preventing people from entering clinical areas and can be used as triage area in case of disaster. It should be visible from reception desk. Provisions for reading material and wall posters regarding health as well as for public relation activity and facilities such as drinking water, ladies and gents toilets, television and channel music are a must in these areas.

Examination and Treatment Area

Main area of trauma department. Going as per patient flow, the various rooms/ areas in this area are:
  1. Triage area

  2. Separate area or lobby may be used.
  3. Nurses and surgeon's station.

  4. It should be near entrance and registration area, with multiple communication modes, may be glass enclosed above counter level, with a private toilet. It should have work area with lockers, refrigerators, counter sink, a small flash steriliser, IV fluids and medicine storage.

    Other features are dispensing/storage cabinets, ample counter and drawer space, CC monitoring, TV for surveillance of holding and treatment areas, bulletin boards, racks for references and manuals, and storage area for supplies. It should have easy approach to clean and dirty utility area.
  5. Examination and main treatment area.

  6. The importance of this area is 'Urgency in diagnosis and treatment' and not any social consideration. It should be large, unobstructed, well-illuminated space for moving heavy equipment, stretchers, and team of health care providers. 11.5 X 11.5 metre for an open trauma treatment room is recommended for access to patient from all sides.

    Treatment spaces/cubicles can be partitioned by curtains or semi-permanent booths. Where cubicles are planned they should be 3.3 X 4.5 metre in size. Doors should be at least 1.6 metre wide.

Resuscitation room

Thirty sq metre room required for stabilisation of injured or acutely ill patients who need care of Airway, Breathing and Bleeding, and Circulation (ABC). It is an equipment intensive area, requiring both diagnostic and therapeutic equipment such as patient's trolley, piped oxygen and suction, adjustable lamps, cupboards, washbasin, worktops, as well as equipment for minor surgeries.

All shelves and drawers must be clearly labelled. It should be connected to emergency electrical supply and from here patient will be moved either to intensive care area, operation theatre, recovery room, treatment room, or transported to a nursing unit.

Operation room

It is required for ease in urgent surgery. There is no requirement of transferring contaminated cases to main OT complex, and schedule of normal OT is not disturbed by emergency cases.

It is preferable to have one room for clean operations and one for septic/contaminated cases. The latter can also be used for plaster room, both of these must provide enough space for staff, instrument trolley, mobile X-ray apparatus, and storage.

Other areas required in trauma centre

(a) Plaster room: It should have provision for orthopaedic and cast work. It should include storage for splints and orthopaedics supplies, traction hooks, X-ray film illuminators and examination lights, plaster trap is a must in the sink.

(b) Surgical ICU minimum of eight beds for a centre handling 1200 cases per annum with attendant facilities, well staffed and equipped trauma ward as a step down facility.

(c) Radiology: Seventy five per cent of trauma patients will require radiographic investigations. This dept may become a bottleneck in smooth flow if not managed properly. Size and facility will depend on relation and distance from main radiology department unless latter is just adjacent, otherwise a satellite X-ray unit is definitely required.

A large X-ray room may be divided by partition into two or three bays, each large enough to carry out an examination of patient on stretcher, besides mandatory mobile unit. It is recommended to have a static 300/500 mA unit dedicated to a large trauma department. CT scan unit for a large trauma centre and dedicated USG facility.

(d) Laboratory: Type and size of laboratory will depend on relation with main hospital laboratory. An emergency facility capable of performing routine blood and urine analysis, bacterial smears and stains definitely is required. Advanced tests such as BGA, and biochemistry may be done in main laboratory.

(e) ECG, blood bank: Closely related to or easy access to a blood bank recommended.

(f) Duty room for doctors and nurses: A nine sqm room each with bed, chair, desk, bookshelf, TV, telephone, lockers, toilet and shower required.

(e) Storage area: Area/alcove for mobile equipment such as mobile X-ray, crash cart, ventilators, and area for storing mobile furniture, clean instruments and linen, drugs, IV fluids, and dirty utility.

(g) Janitor's closet: With a designated space for waste disposal containers.

(h) Administrative areas: Offices for director and matron are required. Conference hall is required in a teaching institute, preferably with a reference library. Pantry of seven sqm for providing hot and cold fluid/beverages round the clock for staff is necessary. Disaster area 90 sqm with lighted open space, close to the entrance, with little fixed furniture and adequate storage spaces.

(j) Communication room: Two way radio communication with ambulances, intercommunication between hospitals, intramural communication in the form of check-in board, PA system, telephone (including hotline), intercom, computer network and dumb waiters for supplies are now a days required in such a modern centre.

Hospital organisation

Level I centre must have the following staff: -
  1. A dedicated trauma medical director who could preferably be a surgeon
  2. Staff
  3. Trauma team:

    1. General surgeon
    2. Emergency physician
    3. Surgical and emergency residents
    4. Nurses
    5. Laboratory technician
    6. Radiology technician
    7. Anesthesiologist
    8. Security officers
    9. Social workers

Training of staff

Training of staff is of utmost importance to run an efficient trauma centre. Training is a continuous process as staff keeps on changing in a large hospital. They should not only be highly proficient in own trade but should also be trained in good human relationship as well. The acute distress, anxiety and urgency on part of patient and relatives should be matched by calm, alert and reassuring attitude of staff. Human relations and human attitudes are consistently put to a very severe test and success depends largely on reputation of hospital and confidence of community in its service.

Ambulance services

An efficient ambulance service is a must for the success of trauma system. The ambulance has been defined by the committee on ambulance design criteria, US, as a vehicle for emergency care which provides a driver compartment and a patient compartment which can accommodate two emergency medical technicians and two lying patients so positioned that at least one patient can be given intensive life support during transit.

Two way radio communication for safeguarding personnel and patient's under hazardous condition and light rescue procedures. It is designed and constructed to afford maximum safety and comfort. It avoids aggravation of the patient's condition, exposure to complication and threat to survival.

Essential requirements for a well organised trauma centre:

  1. Trauma centre should be readily accessible to afford quick transfer of patient from ambulance to bed or operating table.
  2. Efficient , promptly responding, well equipped ambulance service with competent personnel in charge.
  3. Well equipped, trauma operating room with supplies always ready for use.
  4. Recovery room where patient can be sent after emergency treatment.
  5. Efficient hospital personnel always on duty or on call which should include at least a competent surgeon, nurse, and an attendant or orderly.
  6. Supervision of treatment of fractures by a well qualified orthopaedic surgeon, and supervision of the care of other injuries by those who are competent in their respective fields.
  7. Adequate diagnostic and therapeutic facilities under competent medical supervision.
  8. Complete medical record of all patients treated which includes particularly immediate record of injury and a detailed description of physical findings, treatment and results.





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