Legal medicine annual最新文献

A series of 34 cases of SCUBA-related fatalities in military personnel from the files of the Armed Forces Institute of Pathology has been presented. It may be concluded that the potential problems that can occur in the hyperbaric aquatic milieu while using scuba are not completely appreciated by pathologists. The resulting investigations of such fatalities give little hard data relevant to such entities as true incidence of barotraumatic injuries, aseptic bone necrosis, and contaminated air supply, the interrelationship of human, environmental, and life support system factors in such fatalities, and the pathophysiologic sequences leading to drowning or death due to causes other than drowning. Hyperbaric pathophysiology is reviewed with the hope that more reasonable interpretations of cause and mechanisms of death will be possible, and the entities air embolism and decompression sickness are differentiated in a similar light. The importance of the type of SCUBA is discussed, through analysis of ten operational diving fatalities, and the possibility of anoxia, hyperoxic convulsions, and hypercapnia existing with the use of rebreather SCUBA is emphasized. A general approach to the medical investigation of a SCUBA fatality is given, under broad headings including on-the-scene investigation, clothing and equipment examination, external and internal examinations, and toxicologic examination.

In all forms of death the postmortem findings may be divided into two groups. The first group comprises those of general pathologic changes, such as visceral congestion and petechial hemorrhages. These nonspecific changes are always present in a greater or lesser degree in rapid deaths initiated by hypoxia and anoxia as well as in deaths from shock and natural causes. The second group consists of the pathologic changes which are dependent upon the type of death, eg, the local injuries to the neck in throttling and strangulation, and the color of the blood in acute carbon monoxide poisoning. Such changes are best described as special pathologic changes. In the description of postmortem findings for medicolegal purposes, a clear distinction should be drawn between nonspecific general pathologic changes and special pathologic changes which are dependent upon the type of death. All postmortem findings should be considered under the two headings: (1) special pathologic changes; and (2) nonspecific general pathologic changes.

Although each case must be decided on its merits, certain principles founded on case law set the pattern that may be expected to operate in resolving the problem that arises or in aiding a counselor in advising his client, be it physician or hospital. In all situations, the rights of the several parties and the relationships between them must be considered: physician's rights, patient's rights, the patient-physician relationship, the rights of the hospital and the power invested in its governing board, as well as the duties owed by the physician to his patient and to the hospital, and the duty of the hospital to serve the community in which it is situated. All of the foregoing material is a summary of the case law in the various situations that have arisen, as well as the author's expectation as to what might be anticipated in those situations not yet resolved by case law.

Stress exercise testing of suspected or known cardiacs and medical recommendations to patients to undertake physical fitness conditioning exercise programs constitute medical treatment in the eyes of the law and as such render the prescribing and supervising physicians legally responsible for harmful consequences to the patient to the same degree and under the same legal principles applicable for other medically prescribed diagnostic and therapeutic procedures. The physician who employs a stress exercise test or who recommends that a patient engage in exercise as part of a prophylactic, rehabilitative, or therapeutic program must be alert to those aspects of his recommendations which possess potential malpractice hazards. In particular, he should direct his attention to recognized indications and contraindications of exercise test and exercise programs. Furthermore, he should perform an adequate preexercise screening examination and he must make sure that the exercise is properly monitored; that it is immediately terminated upon onset of signs or symptoms of impending serious reactions; that adequate advance preparations have been made for the treatment of foreseeable emergencies, particularly those requiring cardiopulmonary resuscitation and advanced life support; and that such treatment is in full accord with generally accepted and proper medical standards. Finally, the physician must make certain that he adequately informs the patient of the potential risks and hazards associated with exercise stress testing and exercise programs so that the consent to such procedures can be classified legally as valid and "informed".

The major problems of medical and legal causation in traffic-associated fatalities have been reviewed, and the possible pitfalls in relating causation emphasized. In conclusion, the determination and evaluation of causality in vehicular traffic deaths may be a very complex process, requiring special skills and thorough understanding of medicolegal issues. Proper determination of medicolegal causality is crucial to the financial, legal, and medical interests of many individuals and social groups.

Five years following the 1969 passage of legislation patterned after the Model Postmortem Examinations Act, Connecticut has a central laboratory with administrative, autopsy, and toxicology facilities; 24-hour statewide reporting deaths; a records and data-processing system; and affiliation with a university health center. The state's population density, number and size of municipalities and police departments, absence of county government, and judicial appointment of coroner's were unique geographic-political features confronting implementation of the legislation. To effect a transition from the preexisting system, and because of the number of deaths reported and physicians involved, a dual system was developed for examinations and certification of deaths which differentiated autopsies performed at the central laboratory from those at community hospitals. Dissemination of procedures and forms for medicolegal autopsies conducted at community hospitals is planned in the near future. Although educational programs for graduates and law enforcement personnel have been initiated, there still exists a need for more active undergraduate and postgraduate training and a program of research and statistical reporting. Implementation of the statutes during a five-year period in which supplemental legislation and regulations were passed, changes that occurred in state administration, and budgetary restrictions mandated by economic recession has, however, resulted in the nucleus of a modern state medicolegal investigative system--a separately budgeted medical examiner's office, supervised by an independent administrative commission and located on the grounds of the University of Connecticut Health Center in Farmington.