Dr. Dilip Walke lays down the medicolegal steps involved in attending to victims of a road traffic accident. This article puts forth useful pointers to prevent litigation while ensuring quality and swift treatment for an accident victim.

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The management of an accident is not restricted to the medical management of the patient. It is very vital for doctors to know all their statutory responsibilities and the pointers for possible litigations so that not only will the patients benefit from safe medical management but the medical practitioner and the hospitals too benefit from legally safe outcomes.

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Situations when doctors interact with accident victims

Basically, a medical practitioner interacts with an accident victim in three situations.

1. A case of RTA (Road Traffic Accident) brought to a clinic or nursing home or a hospital by some relative or a neutral bystander for treatment.
2. A case of RTA being treated in a small nursing home or hospital; now needing transfer to a tertiary care hospital.
3. A case of RTA needing basic life support from a doctor present on site.

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First situation (A case of RTA brought to the clinic, nursing home or hospital by the relatives or neutral bystanders for treatment)

A common trend amongst doctors seen for several years was to refuse to treat such cases under the pretext that a road traffic accident being a police case, needs to be treated in a government hospital. Such a trend was challenged by Mr Parmanand Katara by a writ in the Supreme Court (writ of 1998 under article 32 of the constitution). Justice Oza and Justice Ranganath Misra judged the writ

Facts of the case presented by Mr Katara were as follows:

A young scooterist (daughter of the petitioner) was dashed by a speeding car on a highway about 20 km away from Pune city. A bystander took her for treatment from one nursing home to other on the highway. Every nursing home refused to treat the patient as it was a “police case”. The patient died on the way to Pune city.

The petitioner impleaded the secretary of MOH & FW, MCI & IMA in the writ. The Judgement referred to the article 21 of the constitution and concluded that saving life is paramount.

1. Duty of a doctor: To save life by stabilising the patient by at least giving first aid. Informing the police and referring to the tertiary care hospital should be done only after giving proper medical aid to save life. Omission to this would amount to medical negligence.
2. Duty of the police: The doctor should be allowed to call the police from any zone to report the case and should not be unnecessarily harassed. All criminal procedures should take a backseat while medical treatment is going on.
3. Court: It should summon the doctor only if it is essential.

Though this is a good judgment, it has some lacunae from the doctor's point of view. Scope of “first-aid” for saving a life is not defined. Whether it is restricted to some injections, dressings, splints or something more is left to the judgement of the doctor. Doctors always have the fear that if some “treatment” is initiated before transferring the patient to a tertiary hospital, they will be held answerable for the treatment in case the patient succumbs or faces some crippling morbidity

Hence, doctors should not only give medical aid to stabilise the patient and save their life but should help the accompanying people to arrange for an ambulance, offer contact details of the tertiary hospital where the patient is being transferred and also seek the help of the police and the local politicians for transfer.

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Second situation (A case of RTA being treated in a small nursing home or hospital; now needing transfer to a tertiary care hospital)

The patient may have been admitted to some peripheral hospital near the site of the accident and treatment already initiated. At some point in time, the doctor may find the need to shift this patient to a tertiary hospital for any of the following reasons:

• Infrastructure and facilities in the peripheral hospital
• The financial condition of the patient demanding that the further treatment be done in a government hospital
• Patient being serious and needing intensive care in a tertiary care hospital

When such a case is taken to the courts for litigation, the common allegations are as follows:

• Inadequate infrastructure in the primary hospital or nursing home
• Transfer without consent
• Wrong choice of tertiary hospital: The patient may have to face difficulties in the tertiary hospital due to cost of treatment, delay for administrative procedures, non-availability of ICU beds etc.
• Ambulance (not arranged/not equipped)
• Doctor not accompanying the serious patient during transfer
• Personnel accompanying not bring trained in basic life support

When to transfer such a patient has to be a collective decision of the treating team of the primary hospital. It should not be too late or too early. The patient should be adequately stabilised hemodynamically before shifting while taking care that the golden hour of surgical management should not be lost

The patient should be transferred to the hospital of choice of the patient or relatives. While shifting to the private tertiary care hospital, the availability of beds should be confirmed. If the choice of the private tertiary hospital is left with the doctors, it is prudent to choose the one with good contacts and rapport, so that further management is handed over smoothly. If the patient is poor, it is prudent to shift to a government hospital, where admission cannot be refused (Keth Majdoor Sangh Vs Union of India).

The three vital documents during this process of transfer are:

• Checklist
• Transfer document
• Transfer consent

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Checklist

Keep a checklist handy so that nothing that is medicolegally important is missed out. It should include:

• Consent & transfer document
• Case papers and reports
• Date, time and vitals at the time of
• Decision of transfer
• Exit from the hospital to the transfer vehicle and when handed over to the tertiary care hospital doctors
• Documentation of reasons for transfer
• Name and qualification of the accompanying person
• BLS/ACLS certificate of the accompanying person
• Details of equipments in the ambulance
• Details of emergency tray
• Documentation of patient monitoring during transfer

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Transfer document

It is a document to be attached to the transfer note of the patient so that the receiving tertiary care hospital gets a complete understanding of the treatment already received. The document should include the following:

1. Name of the patient/ identification mark
2. Reasons for referral
3. Date and time of referral- decision/shifting to the vehicle/reaching the tertiary hospital
4. Details of vitals at every stage of transfer
5. H/o co-morbidities
6. Indoor paper copy and operation/procedure/life-saving measures details
7. Investigations
8. Transferred in an ambulance
   1. Yes/No. If no then which vehicle? Arranged by whom?
   2. Accompanied by: Names and qualifications of doctor and staff nurse
   3. Equipments: Oxygen cylinder/monitor/pulse oximeter/syringe pump/bag-mask/portable ventilator
9. Emergency tray contents
10. Monitoring details during transit: Pulse/BP/saturation/respiratory rate
11. Details of any event during transit
12. Name and contact number of the doctor/staff of the tertiary care hospital contacted to be given to which relative

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Transfer consent

It is a cautious practice to take a consent for transfer from the patient or relatives, because it saves the doctor from several possible allegations in the court later. However, one has to understand that this consent is not comparable to consent taken for surgery or procedure. It is merely a declaration taken from the patient or the relatives. Hence, in case of emergency, if obtaining such a consent is missed, it does not amount to trespass or medical negligence.

Following is an ideal transfer consent:

I,…………………………………………………….aged………….years, female residing at ………………………………………………………………………………………………………………..

give my free and valid consent for transfer of myself/my …………………. (relation),(Mr./Mrs……………………………………aged …………. years residing at

………………………………………………………………………………………………………………..

1. I/We understand that further treatment will be carried out at……………… hospital.
2. I/We state that:
3. I/We have been explained about the nature of the disease of the patient. I/We have been explained the following:
   1. Nature of transfer to higher centre.
   2. Its purpose, benefits and effect;
   3. Alternative hospitals for transfer.
   4. An outline of the substantial risks involved during transfer
   5. Adverse consequences of refusing transfer
4. I/We were made aware of the available medical equipment’s, infrastructure and amenities of this hospital at the time of admission.
5. I/We were made aware of the available medical equipment’s, infrastructure and amenities of the hospital where the transfer is proposed.
6. I/We have agreed to the chosen higher healthcare centre for transfer.
7. I/We have been provided adequate information about the hospital where the transfer is being done. This includes address, contact number, details of doctor.
8. I/We have agreed to the chosen mode and vehicle of transfer after gathering information by a discussion with the hospital authorities and medical team
9. I/We are aware that during transport limited monitoring and treatment is feasible
10. I/we have been provided with the relevant transfer documents
11. I/We have been encouraged to ask any questions related to the transfer and all the answers were understood.
12. I/we having understood all that is mentioned above, give free consent willingly with a sound mind, without any undue influence, coercion, fraud, misrepresentation or mistake of facts.
13. Space for signature or thumb impression of patient/relatives/witness (space for a handwritten declaration if signatory does not understand English)

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Further steps to prevent litigation

Doctors have to remember that it does not end with the transfer of the patient. The following is essential to prevent litigation:

• Visiting the patient in the referred hospital at a reasonable time interval
• Developing a rapport with the ICU staff
• Participating in the counselling sessions with the relatives
• Showing empathy in the event of mishap

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Third situation (A case of RTA needing basic life support from the doctor present on site)

Doctors like the general population have become insensitive to a dying victim of a road traffic accident. Ministry of Road Transport and Highways statistics say that every 24 hours there are 1317 crashes and 413 deaths. More than 50% of these accident victims die because there is no help in the golden hour.

The reasons for this insensitivity are:

• Fear of being harassed by the police
• Fear of being detained in the hospital and getting involved in the legal formalities and court case later

Hence, there is a shortage of good samaritans in our country. A good samaritan is a person who, in good faith, without expectation of payment or reward and without any duty of care or special relationship, voluntarily comes forward to administer immediate assistance or emergency care to a person injured in an accident, or crash, or emergency medical condition, or emergency situation.

India did not have a “Good Samaritan” law for all these years until there was a writ in the Supreme Court in 2012 (Save Life Foundation Vs Union of India).

The supreme court, on 30th March 2016 proposed a “Good Samaritan Law” bill to be adopted by all states and to be included in the Motor Vehicle Act of 2019. Ministry of Road, transport and highways guidelines were referred to and SOPs for good samaritans were issued. Hence, 30th March is celebrated as a “Good Samaritan Law” day. However, a survey by the “Save Life Foundation” reports that 80% of Indians do not know about the bill.

On 8th and 9th August 2020, Thozan (a Chennai based NGO) organised the first mega online awareness campaign in this regard for students to general public. More than 2750 people participated and drafted a letter to the PM to pass it as a law in the parliament as soon as possible.

The proposed SOPs are as follows:

• Allow the GS (good samaritan) to leave the hospital immediately after admitting the victim
• Giving one’s detailed identity should not be compulsory for the GS
• Police should not involve the GS in the investigation
• Unless related to the victim, do not charge the GS for registration etc.
• Should not insist on knowing his/her name upon receiving a call for reporting any accident
• Hospitals should not charge the GS for first-aid.
• The good samaritan should be protected from civil and criminal liability
• The good samaritan should not be compelled to become an eyewitness
• The good samaritan should be adequately rewarded as per guideline of the state government
• Disciplinary and departmental action should be initiated if any government official intimidates or coerces a GS
• Not to harass the eyewitness in court-limit the summons/use video conferencing

Certain questions which need to be answered in the act about doctors as good samaritans are:

• Is it applicable in the hospital too for “off-duty doctor”?
• Will medical negligence by a GS doctor be protected? To what extent?
• Will it protect all “non-medical” assistance steps too?

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Conclusion

Laws in our country will have to mature in the coming years with regards to the care of accident victims because the incidence of such accidents is on the rise. Every victim of a road traffic accident deserves quality care and every caregiver deserve a fearless atmosphere to provide such care.

This article was originally published on 22 April 2021.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

Dr. Walke is Dr. Dilip Walke is a former head of ethics and medicolegal committee of FOGSI.

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