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Ethics in Emergency Care

Ethics in Emergency Care

India requires a better emergency medical service to meet the growing number of emergencies. What exists currently in the form of fragmented services across the country falls way short of meeting the requirements?  Let alone rural and semi-urban areas even in metros emergency care is woefully inadequate. It is terms like ‘The Golden Hour’ and the ‘Platinum Ten Minutes’ that typify the importance of Emergency Medical Services (EMS). It is a well-accepted fact that a patient who receives basic care from trained professionals and is transported to the nearest healthcare facility within 15-20 minutes of an emergency has the greatest chance of survival. EMS is an essential part of the overall healthcare system as it saves lives by providing care immediately. Over the years several advancements have been made and research is underway to create services that provide medical assistance to patients at the earliest. In spite of the development in the healthcare sector over the past decade, India is yet to create a single, comprehensive EMS that can be accessed throughout the country. Emergencies typically occur in cases like road accidents, cardiac problems, convulsions and so on. Trained technicians or paramedics provide first aid to the patient i.e. pre-hospital care and shift the patient to an appropriate facility. EMS can be provided in two forms—treatment to in-patients and pre-hospital services. Pre-hospital medical services include ambulatory services, transportation of the patients to or from places of treatment and acute medical care. Importance of pre-hospital services is all the more since even after reaching hospital the casualty may have to wait for a long time due to rush of work. Trauma continues to be one of the major causes of death in India. 108 is predominantly an emergency response system primarily designed to attend to patients of critical care, trauma and accident victims. Ambulance availability is poor. Hospitals are crowded. Trained staff is not available.  Blaring sirens, frustrated calls to action, exchange of expletives and anxiety have come to define ambulance movement on the city’s chaotic roads which emergency responders say have turned unforgiving over the years. Making emergency medical service legally compulsory without ground level preparedness will not be enough.” He adds that people need to be aware of their responsibilities toward fellow citizens and insist on and be aware of the best emergency service available.

An ordinary doctor is always intimidated in dealing with a serious patient and the medico legal aspects that is generally associated with such cases. Uninvited legal battle, pestering by the law enforcement agencies, wasting precious time as a witness whenever called upon into the court of law are some of the common apprehensions of a doctor. These intimidations are a deterrent to offer services.  The rationale behind the complicated procedure is to keep all the evidence intact. There is a small window of ‘life or death’ of an injured person which is at jeopardy between the fulfillment of these legal obligations and receiving medical attention. The recognition of Emergency Medicine as the 30th specialty in medical training by the medical council of India in July 2009 brought about a welcome change. There is now a move to increase the number of eligible seats for training in emergency medicine throughout the country. What we need is the money, the honesty and the will to do a decent job.

A  Committee under the Chairmanship of the Director-General of Health Services (27-04-1985) had taken the following decisions:  On arrival of a medico legal case, the medical officer on duty should inform the duty constable the following details of the patient before he starts with the required treatment; Name, Age, Sex, Place of accident occurrence, Time of accident occurrence.   The constable on duty should report the incidence of casualty to the concerned police station or higher police functionaries.  A Medical officer is liable to prepare and handover a detail report of the case to the constable as soon as the examination and treatment is over.  The treatment of the patient would not wait for the arrival of the police for completing legal formalities. Cases brought by the police should be assigned to specific zonal hospitals. Immediate medical assistance should be provided by all Government Hospitals, Medical Institutes irrespective of the medico legal case or otherwise.  The Primary Health Centres (PHC) should attend the patient and give proper medical aid . Emergency Medical Officer (EMO) should admit a patient whose condition is serious. Casualty hospitals or trauma unit should be set up at some points on the regional basis.  MO should mention his full name and signature in the treatment document.  Such records should be kept in safe custody by the MS.

It is only ethical that physicians should be ready to respond to the calls of the sick and injured patients. He should never forget that the health and lives of those entrusted to his care depend on his skill and attention with promptness.  No physician shall arbitrarily refuse treatment to a patient. A physician should refer the patient in case if the ailment of the treatment is not in the scope of the treating physician. The physician should neither neglect or nor withdraw from the case without giving adequate notice to the patient and his family, once the case is undertaken.  The Medical Council of India expects that all medical practitioners attend to sick and injured immediately and it is the duty of the medical practitioners to make immediate and timely medical care available to every injured person whether he is injured in an accident or otherwise. A doctor should not feel handicapped in extending immediate help is such cases fearing that he would be harassed by the law enforcement agencies or dragged to the court relating to this matter.

Fear of complications in surgery

There is an old saying that “the only surgeon without complications is the surgeon who does not operate.” So, surgical complications have been an inevitable part of surgical practice.  Surgeon cannot deny treatment on account of this fear. What does a surgical complications involve?-It is a complication that is undesirable, unintended, and direct result of surgery affecting the patient which would not have occurred had the surgery gone well.  Recently, the National consumer Commission has declared that the unsuccessful surgery due to an errorless protocol or procedure is not anymore considered as medical negligence. There are four principles of medical ethics i) Respect for autonomy; requires doctors to respect a competent patient’s deliberated wishes and provide adequate information to support patients in their decision-making. Ii) Beneficence; this should be for the  benefit  of patients by acting in their best interests. Iii) Non-maleficence; not to cause any harm to patients. Iv) justice;  primarily refers to the obligation to distribute limited health care resources fairly. it is surgeon’s ethical responsibility to disclose any side effects or complications involved in any  procedure.

It has been observed that surgeons are likely to underestimate harms and overestimate benefits of treatments. There is also a proposed “therapeutic illusion,” in which clinicians see surgical interventions in a more positive light, especially ones they are more familiar with. One of the studies, which compared two specialties, found that clinicians were likely to think more highly of the intervention that they provided. Patient interest should always be supreme and ethics should dictate ‘life saving’, under all circumstances.


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