1. INTRODUCTION
If your view of Accident & Emergency medicine is conditioned by 'Casualty' or
'ER' then my major aim in this article is to disappoint you.
Although the patients seen during 'Casualty' are based on real cases which present
to Accident & Emergency departments, those seen during one fifty-minute
episode would normally not turn up in a period of a day but may appear over
about a month, and some of the clinical situations that appear routine in the series
are seen less than once a year in an average department.
As with most other professional occupations the majority of the work of Accident
& Emergency Medicine is not concerned with life-threatening emergencies, which
make good television, but with illnesses and injuries which affect people's quality
of life rather than its quantity.
The aim of this article is to show the range of experience of an Accident &
Emergency Consultant and the types of professional services which he or she may
be able to provide to the legal profession.
Consultants in Accident & Emergency are drawn from a variety of medical
backgrounds; medical, surgical and anaesthetic. Their higher training involves all
of these disciplines and culminates in the awarding of the Fellowship of the
Faculty of Accident & Emergency Medicine (FFAEM). The Faculty is an
intercollegiate body, drawing on support from the Medical, Surgical and
Anaesthetic Royal Colleges.
Consultants in Accident & Emergency have responsibility for all the patients that
present to their departments, but over time most develop clinical, research and
other interests within the speciality.
Most departments have annual attendances of about 50,000 new patients (i.e.
about 140 every day). The majority come as a result of accidents, either in the
home or workplace, or on the road. Another group present as a result of violence
and some as a result of sport.
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2. HOW THE ACCIDENT & EMERGENCY CONSULTANT CAN ASSIST
THE LEGAL PROFESSION
Many consultants have developed specific interests in medico-legal matters, either
prior to or after their appointment. Many have also developed a close working
relationship with both the legal profession and the justice system.
I wish to consider three areas where it may be appropriate to use the expert advice
of an Accident & Emergency Consultant in the interests of an individual client.
These are (a) personal injury cases, (b) medical negligence cases and (c) criminal
cases.
(NB. Accident & Emergency Consultants can also be used to give general
background help on a wide range of medical matters).
(a) PERSONAL INJURY CASES
There has been an explosion in the number of personal injury claims in recent
years, due to a combination of factors. Many more people are claiming for less
severe injuries.
Even recently, the advice to those involved in personal injury work was that in
most cases an expert report should be supplied from an orthopaedic expert. At the
other extreme 'The Legal Executive' journal has indicated that in a minor injury
the expert evidence of a GP might be all that is necessary to provide medical
evidence to the court.
Most of the patients injured in an accident, whether road traffic accident or works
accident, when treated in hospital are seen and discharged from the Accident &
Emergency Department without being seen by an orthopaedic surgeon.
Many do not see their GP for follow-up and the GP consequently has no medical
records pertinent to the accident. In order to prepare a report on such a case it will
therefore be necessary for him to see the patient, and the cost will be similar to a
Consultant's report.
The majority of the treatment for soft tissue neck injuries (whiplash injuries) and
hand injuries is carried out under the care of Accident & Emergency Consultants,
who have specialist experience and are able to give prognosis reports on these
injuries.
There is also a role for the Accident & Emergency Consultant to help with an
overview of a seriously multiply-injured patient's initial care and to give the lawyer
guidance as to the specific experts that may be needed to give a complete picture
of the prognosis of the patient.
(b) MEDICAL NEGLIGENCE CASES
Accident & Emergency departments are busy places. The average department has
a patient registering every 10 minutes, every hour of the day, every day of the
year.
Consequently, it is not surprising that sometimes patients feel that their care is
sub-standard. Most of these are a moderate size of claim (the average damages for
a medical negligence case in Accident & Emergency is around £15,000) but the
total risk for an Accident & Emergency department places it second behind
Obstetrics in the total amount of claims in a given period for an individual hospital.
It can, therefore, be seen that in order to provide evidence to support a claim of
sub-standard care that care must be assessed by an independent expert.
With the changes that are occurring in Accident & Emergency care, including the
expansion of the speciality, it is now incumbent that the expert chosen to provide a
report on the liability aspects of care in the Accident & Emergency Department
should be a specialist who spends his or her working life in that environment.
I have heard experts who think they know what standard of care is appropriate for
a particular patient discussing the aspects that an Accident & Emergency junior
doctor should be expected to know.
These in-hospital specialists, whilst having undoubted expertise, do not work in
the Accident & Emergency environment and the appropriate expert should,
therefore, be a Consultant who has specifically trained in the speciality and who
works there for most of the working week.
Accident & Emergency Consultants deal with patients only during the initial part
of their illness. They can, therefore, produce reports dealing with liability issues in
medical negligence in Accident & Emergency departments but the causation and
prognosis reports probably fall outside the remit of an Accident & Emergency
Consultant.
(c) CRIMINAL CASES
Many patients present to an Accident & Emergency department for treatment
following an assault. Most Consultants have had experience both of a range of
injuries and the causation of these injuries (both the real causes and the causes
claimed by some of their patients, which may not necessarily be the same).
Indeed, the prosecuting authorities routinely ask for witness statements from
Accident & Emergency doctors as to the injuries which victims of assaults have
sustained.
Most of these statements are accepted as fact by the defence in minor or
moderate cases. The cause of the injuries may be in dispute and there is scope for
expert assessment of the medical evidence to present an independent opinion to
the court.
While there are some independent forensic medical examiners (e.g. police
surgeons) most Consultants in Accident & Emergency who have an interest in
forensic medicine have the necessary experience to provide such a service to
lawyers.
Indeed, in the case of wounding, where the average Accident & Emergency
Consultant sees more traumatic wounds from all causes, including non-violent
wounds, than the forensic examiner, he is in a better position to assess the truth of
varying accounts given as to the cause of specific injuries.
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3. TEACHING BASIC MEDICAL SKILLS
Many Accident & Emergency Consultants have an active teaching commitment in
their Department. Many, also, are happy to speak to groups of the legal profession
about aspects of medicine, either basic science, such as anatomy, or the treatment
of specific injuries or illnesses.
This is particularly useful as the type of patient which an Accident & Emergency
Consultant deals with on a daily basis normally approaches the legal profession
when something has gone wrong. Either they have been charged following an
assault or they have been injured.
Fostering good relations and understanding between the medical and legal
professions is the key to providing the patient / client with the help which he or
she needs. This is aided by an understanding of the work each other does and the
background which underpins that work.
Accident & Emergency Consultants have skills which can help in this process, and
I hope that your perception of those running Accident & Emergency Departments
and their work has been altered by this article, from the view presented by the
media to an understanding of the many parts of their working life which can bring
them into contact with the legal profession.
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