Medical Officers on duty at private hospitals and general practitioners at private clinics need to know the following processes for dealing with medicolegal cases arriving at their hospital/clinics.
- All types of trauma patients are given to First aid / life-saving emergency care according to the new law relating to first aid and emergency care for accident patients.
- They have to refer to the appropriate government hospital with proper referral letter.
- They have to note on the medico-legal case register books at the hospitals and clinics.
- They have to take medical history and record the history taking, physical findings, investigation results and reason for referral on the hospital books and clinics books.
Medicolegal Report is used at government hospitals only. It is not used at private hospitals and private clinics but medicolegal case register has to be kept there for the record. Therefore, all medicolegal case patients have to be referred to government hospital.
The emergency medical officers and general practitioners should write the referral letter, including :
- Patient’s name, age, sex, father’s name, address, contact hand phone number, name and address of person who accompanied / brought the patient;
- Date and time of arrival at the hospital;
- Patient’s register number;
- Brief and relevant history (e.g. Mechanism of injury);
- Main complaints, findings (wound description, vital signs and relevant investigations), provisional diagnosis and treatment, reason for referral;
- Signature of doctors who examined the patients;
They should also note on the medicolegal case register including:
- Column (1) date and time of arrival
- Column (2) patient’s particulars
- Column (3) brief and relevant history
- Column (4) description of wounds, vital signs, investigations done, provisional diagnosis and treatment given
- Column (5) nature of wound and weapon used
- Column (6) remarks
- Column (7) name and signature of doctors who examined the patient
History from the patient or caregiver is not always true. So do not rely totally on the history. It should be a detailed history in the patient’s own words (narrative form). The statement should start with the words ….. the patient or caregiver said ……….. ..………………………..………………………………………………………
Mechanism of injury is very important. It can be known from detailed history taking.
How did it happen? (who, what, when and how)
Mode of sustaining injuries is also important. Are the injuries caused by assault, accident or suicide? The accident may be at home or occupational accident. The injuries caused by self or marital violence.
The medical officers on duty at private hospitals and general practitioners at private clinics have to know proper wound description when they examine the wounds over the patients. These are nature, number, site, size, shape, lie and direction of the wound; edges and ends, any foreign body and source of bleeding identified.
It should be descriptive and not in a tabulated form.
NATURE – stab wounds, incised wounds etc.
NUMBER – Best description- from top to toe, front and back, and right and left. OR another school of thought- injuries, which were received first, were described first (not very easy)
SITE – described in two planes, in relation to prominent anatomical landmarks. In females, avoid using the nipple as a landmark.
SITE – described in two planes, in relation to prominent anatomical landmarks. In females, avoid using the nipple as a landmark.
SHAPE – may be circular, oval or spindle shaped (in stab wounds).
Draw a diagram especially if the shape is irregular and difficult to describe.
DIRECTION – described in 3 directions.
forwards / backwards
upwards / downwards
inwards /outwards
LIE – horizontal lie, vertical lie – in relation to clock face e.g. 4 –10 0′ clock lie.
You must stand at the foot end of the body and describe them.
EDGES – regular (clean cut) or irregular
-may be bruised
-may find hilt impression marks (in stab wounds)
ENDS – both ends sharp or one end sharp and another blunt (rounded)
– tailing present or not
FOREIGN BODIES – tip of dagger in vertebral bodies
– pieces of glass in head hairs
SOURCE OF BLEEDING – only major vessels are described.
A lacerated wound over the bony eminencies. e.g.over the scalp, face, eyebrow, iliac crest, on casual examination resembles an incised wound (caused by a sharp weapon) and thereby interpretation of the weapon could be wrong. But, on careful examination: –
- if split skin is stretched so that it gapes, you will find there are bridging across of tissues (nerves, vessels, tendons) especially at the 2 ends.
- Edges are irregular.
- Always some degree of bruising of edges (margins)
- If the wound is on a hairy area – pieces of hairs may be embedded in the wound and the hair bulbs are crushed (instead of being cleanly cut).
- Underlying bone may be depressed or linear fracture.
- Bleeding is less profuse than that of incised wounds because there is some degree of bruising and crushing of the margins which release histamine like substances acting as haemostasis, and vessels are crushed instead of cleanly cut.
If it is due to an incised wound caused by a sharp cutting instrument: –
- No bridging of tissues
- Edges are regular (clean cut)
- No bruising at the edges
- Hairs – cleanly cut
- Underlying bone – clean cut fracture
- Bleeding – more profuse because vessels are cleanly cut
Split skin injury is usually found in scalp injuries caused by blunt weapons (sticks, bamboo, iron rods, bricks, some hard object on the ground). Similar injury occurs in boxing (split eyebrow). Small splits can result from kicking with a boot.
Photographs of the wounds should be taken as hospital reference. It is not generally accepted as legal evidence. It should be kept confidentially in photograph register of private hospital. First of all, the medical officers on duty at private hospitals and general practitioners at private clinics obtain informed consent to photograph the wound for proper wound documentation in the patient chart from the patient or care giver. They have to Photograph to identify the patient and to identify the injured area and then close up photograph before cleaning the injuries and after cleaning the injuries. When they are photographing, a ruler or measuring tape in centimeter for scale and a label including patient register number and date taken have to be included in the photographs.
The medical officers on duty at private hospitals and general practitioners at private clinics have to note down the investigative findings and the results including date and time, the X-ray findings including X-ray Number, date and time; the findings of CT including CT Number, date and time; the operative findings including date and time; date and time of admission; date and time of discharge and discharge status e.g. healing of injury, vital signs, etc., reason for referral to government hospital. The investigation results at private hospital and private clinics are not valid in medico-legal report but the results are used in treatment decision at private hospital and private clinics. In the referral letter, the relevant negative findings must be noted down e.g. No foreign body, no obvious fracture seen in X-ray (in such case … you may write down your suggestion to patient to do .. e.g. CT head, USG abdomen etc.).
When the doctors are making a correction on the medico-legal case register book and other medico-legal documents, the wrong word must be scratched through with one line, fully signed, name and dated. They do not use eraser or white off or over correct.
Formally, the emergency doctor has to inform to specialist and ward in charge when medico-legal case patients arrived at private hospital. If it is necessary, they inform directly to hospital admin. The doctors practice with respect of professional secrecy and keep special records of medico-legal cases. All medico-legal documents are confidential.
When induced abortion patients arrived at private hospital and private clinics, the doctors face some legal problems. Is it mandatory to report a case of criminal abortion to the police? Would a doctor be committing an offence for failure to report a criminal offence? Would be breaking professional secrecy if they report to the police?
Under Criminal Procedure Code Section 44 – a person who is aware of a criminal offence listed under this section must give information to the police (e.g., treason, murder.) Failure to do so may lead to punishment of 1 month or fine or both. M.P.C Section 312, 313 and 314 are not included under the above section. Therefore it is not mandatory to report a case of criminal abortion.
But it is necessary for a doctor who treat a case of criminal abortion to note down the history and the medical findings precisely and to preserve the medical records and relevant evidence associated with the case. It is a criminal offence if a doctor intentionally destroys such records and evidence.
A doctor’s first duty is to treat the patient and keep the rules of professional secrecy. The police are not interested in cases of self-induced abortions. But if a professional abortionist is involved, and the patient is liable to die, then the doctor should urge the patient to report to the police. If she refuses to do so the doctor should continue to treat her and note down the medical findings. A dying declaration should also be taken from the patient. Should the patient die, the case should be reported to the police and a medico-legal post-mortem examination must be done at the government hospital before issuing a death certificate.
It should also be noted that it is regarded as an “infamous conduct” for a doctor to perform a criminal abortion and he or she could be de-registered by the Myanmar Medical Council.
In suspected poisoning cases arrived at private hospital and private clinics, at fast, the doctors give the first aid and emergency treatment and then refer the patients to the poison center of new Yangon General Hospital. They take brief and relevant history and then they identify and retain any drugs or possible poisons if they find.
It is not mandatory to report to the police except homicidal poisoning cases.
When may a doctor issue a death certificate?
- The doctor issuing the death of must be a registered medical practitioner.
- He must have been in attendance during the patient’s last illness.(usually 14 days) In some cases, when the doctor was attending the deceased regularly and had seen the body after death the certificate may be accepted even though the last attendance was more than 14 days. A doctor who sees the deceased for the first time after death should not issue a certificate.
- He must know the cause of death.
- He must be satisfied that the cause of death is a natural one; otherwise if it is a suspicious or unnatural death he must refer it to a hospital for medico-legal post-mortem examination.
If the patients die at private hospital or private clinics, the medical officers on duty at private hospitals or the general practitioners at private clinics have to write down and sign on the medical certificate of cause of death (Form 200) and then send to the respective Township Medical Officer. The Township Medical Officer give Medical Certificate (Form 203) (in Myanmar language) and burial certificate (Form 204) to the first relative of the deceased.
The cause of death must be recorded in the correct sequence as described below.
- (a) Immediate cause x Time interval from onset to death
(b) Antecedent cause x Time interval from onset to death
(c) Underlying cause x Time interval from onset to death - Contributory cause
e.g., I. (a) Cerebral haemorrhage x 1 day
(b) Hypertension x 5 years
(c) Chronic nephritis x 10 years
II. Chronic bronchitis x 4 yearsExamples of certain causes of deaths
I. (a) Shock and haemorrhage x 15 minutes
(b) Haematemesis and malena x 50 minutes
(c) Ruptured oesophaegeal varices x 50 minutes
(d) Cirrhosis of liver x 8 monthsII. Chronic bronchitis x 4 years
- (a) Acute Myocardial infarction x 1day
(b) Coronary atherosclerosis x 5 years
I.(a) Cerebral compression x 1 hours
(b) Subdural and subarachnoid haemorrhage x 3 hours
(c) Head injury x 3 hours- (a) Septicaemia x 5 hours
(b) Generalised peritonitis x 1 day
(c) Stab wound ascending colon x 2 days
(d) Stab wound abdomen x 2 days- (a) Septicaemia x 5 hours
(b) Generalised peritonitis x 1 day
(c) Incomplete abortion x 10 days- (a) Septicaemia x 4 hours
(b) Bedsores x 8 days
(c) Prolong bed rest x 20 days
(d) Lumber spine injury x 20 days
References
- The Law relating to private health care services (5th April, 2007), The State Peace and Development Council, The Union of Myanmar
- Lecture notes on Forensic Medicine for Final Part (1) MBBS (Volume 1,2 and 3), (2022), University of Medicine 1, Yangon, Myanmar
- Medico-legal guidelines for Medical Officers (December, 2017), Ministry of Health and Sports, Myanmar
- Professor Dr.David Kyaw (27th December, 2014), ‘Symposium on Professionalism, Bioethics and Medico-legal Issue’
- Improving cause of death information (July, 2017), University of Melbourne, Australia
Author Information
Professor Dr. Aung Soe
Head of Department of Forensic Medicine (Retd.)
University of Medicine 1, Yangon
Chief Police Surgeon, Yangon General Hospital (Retd.)
