Emedinews:Insights on Medicolegal issues: Fracture of bone–Grievous injury

The certification of grievous injury on the basis of fracture of bone is done by doctors in accordance with Section 320 IPC, which lists the injuries that are called grievous injury.
• The medical dictionary meaning of the word ‘fracture’ is breaking of a part, especially the bone or break or rupture in the bone or in continuity of a bone This definition is appropriate for the radiologist or orthopedician, but not for the purpose of certifying an injury as grievous since in many cases in legal scrutiny it has been found that the fracture reported by radiologists were tentative, superficial, fabricated or self-inflicted, hardly 1 mm deep cut in the bone or mere a ponding effect on bone with no medical or surgical complication.
• It is important for the doctor to understand that a tentative fracture medically/clinically non-significant/uncomplicated/invented by modern scan methods cannot be certified as grievous injury.
• A mere superficial cut and scratch on bone may not be grievous because the meaning of grievous is.. threatening great harm; "a dangerous operation"; "a grave situation"; "a grave illness"; "grievous bodily harm"; "a serious wound"; "a serious turn of events"; "a severe case of wound or a life–threatening disease
• It must be remembered that the cutting of a bone does not necessarily involve a fracture of that bone. In a criminal revision at the Patna High Court, in which one individual received an incised wound, 3" × 3 ¼" × 1", on the lower part of the left leg cutting the bone underneath, it was held that where the evidence was merely that the bone had been cut and there was nothing whatever to indicate the extent of the cut, whether deep or a mere scratch upon the surface, it was impossible to infer from that evidence alone that grievous hurt had been caused within the meaning of the definition of section 320, IPC.
• The supreme court in its judgment, in one case, had clarified that until and unless such a cut on bone does not extend deep up to the medullary cavity it will not constitute a grievous hurt within the definition of fracture under section 320(7) of Indian Penal Code.
• In case of hurt it is the Court that judges finally whether the injury is simple or grievous. The duty of the medical witness is only to describe the facts and not classify a hurt. The entry made in the wound certificate as simple or grievous is only meant to guide the investigating officer

Emedinews:Inspiration:The Making of a Champion

I have often thought about Muhammad Ali's fight against George Foreman in October of '74. Hyped as "The Rumble in the Jungle," it's a lesson of how to win in life. The Muhammad Ali story is a victory that people still talk about to this day. In the city of Kinshasa, Zaire, Ali faced George Foreman, the reigning world heavyweight champion. Foreman dominated the ring, winning 37 of his 40 bouts by knockout. Weeks before the fight, Ali had captured the heart of the Zaire people when he cast Foreman as a brute. Foreman, never the showman Ali was, believed his record would speak for itself.
Considered one of the hardest hitters in the history of boxing, Foreman punched his way through the early rounds with little resistance from Ali.
Muhammad ducked the worst of his punches, leaning against the ropes, protecting his face with his elbows, a technique that later came to be known as "rope-a-dope." This technique served to lessen the effect of Foreman's punches. The tactic continued throughout the seventh round. Ali fans were subdued, discouraged to watch their champion do nothing to defend himself. Ali provoked the raging Foreman with sarcastic jabs, taunting him, "Is that all you got George? and You supposed to be bad!" Foreman let loose his rage, landing tremendous body shots, determined to make Ali pay a price for his antics.
No one knew it at the time, not his trainer Angelo Dundee, or us, his devoted fans, but Muhammad Ali had a plan that was secretly unfolding before our eyes. I remember that day, although I don't recall seeing the fight until years later, rebroadcast on the Sports Channel, but in my heart I was there, sitting ringside, lamenting my hero.
Ali knew Foreman relied on phenomenal strength to overpower an opponent and had rarely gone the distance. He believed that could be his Achilles heel and concluded that the only smart thing to do was wear him out. When Foreman became tired, overconfident because Ali was not fighting back, that's when he would make his move. Ali was willing to let us see him as a failure because he never saw himself that way. Isn't that the heart of a true champion? To quietly go about doing what must be done, having enough confidence in them not to feel like they need to prove anything?
Although I believe failure was never an option in Ali's mind, he was willing to be seen as one, willing to be put under the microscope in front of the whole world. How many of us would be willing to be seen in this light? To be viewed as a failure before those who admire us? Ali was so sure of himself he was willing to try. Not long into the eighth round, George Foreman's energy finally spent, staggered. Ali sprang from the ropes and landed three beautifully-timed punches. Foreman twirled in a slow pirouette and fell. The fight was over.
Sometimes when we allow ourselves to be quiet about what we know and silently go about mastering our opponent, we can impart something to others. Ali did that. He was an example to each of us - willing to be seen as nothing, to become the greatest. Ali said it then, even if he didn't mean it at the time. He was the greatest. Ali didn't surrender that evening; our vision of him had. When he lifted the veil from our eyes we were filled with admiration. Perhaps he could have won that fight, as he had so many others, but that battle, the one Ali came back to win, stands out as one of his greatest. A victory like that can have such a long-lasting effect.
I think that's what each of us should do. We should never be afraid to be seen as nothing in order to become something greater than we ever imagined we could be. Remembering if we only follow our convictions, each challenge, every obstacle before us, can be overcome to impact the lives of others.

Emedinews:Makesure:A diabetic hypertensive was denied a beta–blocker because of the traditional teachings.

Situation: A diabetic hypertensive was denied a beta–blocker because of the traditional teachings.
Reaction: Oh my God! You should have used nebivolol.
Lesson: Make Sure that diabetics are not denied beta-blockers when indicated. Nebivolol has no side effect on glucose metabolism unlike atenolol.

Emedinews:Insights on Medicolegal issues:Grievous injury Section 320 Indian Penal Code

1. Emasculation: It means depriving a male of masculine power.
2. Permanent privation of sight of either eye: The gravity lies in the permanency because it deprives a person the use of the organ of sight.
3. Permanent privation of the hearing of either ear: It deprives a man of his sense of hearing. Injury to the tympanum or auditory nerve or by thrusting something into the ear which causes deafness.
4. Privation of any member or joint: The term ‘member’ means an organ or a limb being part of man capable of performing a distinct function. It includes, nose, mouth, hands, feet, phalanges etc.
5. Destruction or permanent impairing of the powers of any member or joint: the use of limbs and joints of body are essential to the discharge of the normal functions of the body. Their deprivation causes lifelong crippling and makes the person defenseless and miserable.
6. Permanent disfiguration of the head or face: The word ‘disfigure’ means to cause some external injuries which detracts from his personal appearance but does not weaken him
7. Fracture or dislocation of a bone or tooth: It is not necessary that a bone should be cut through and through cut should be up to the medulla. If there is a break by cutting or splintering of the bone or there is a rupture or fissure in it, it would amount to a fracture but the doctor must document the dimension of fracture and duration/age correlation with age of injury. Dislocation means displacement. Mere looseness of teeth will not amount to dislocation. It has to prove that the tooth was originally not loose and that there was fracture or dislocation by the injury.
8. Any hurt which endangers life or which causes the victim to be in severe bodily pain or unable to follow his ordinary pursuits for a period of 20 days: A wound may cause intense pain, prolonged disease or long lasting body injury but does not fall under any of the seven clauses. A body injury/beating may not mutilate the sufferer or fracture his bones but may be so harsh and painful may cause even death. The eighth clause provides for such hurts. Under this, three different clauses of hurt are included. These are:
• Any hurt which endangers life
• Any hurt which causes the victim to be in severe bodily pain for a period of 20 days
• Any hurt which prevents the victim from following his ordinary pursuits for a period of 20 days

Emedinews:Inspiration:The Oak and the Reeds

There is an old fable in which the mighty oak tree which stood for over one hundred years finally was blown over by a storm. The tree feel into a river that floated it downstream until it came to rest among the reeds growing along the riverbank. The fallen giant asked the reeds in amazement, "How is it that you were able to weather the storm that was too powerful for me, an oak tree, to withstand?"

The reeds replied, "All these years you stubbornly resisted the winds that swept your way. You took such pride in your strength that you refused to yield, even a little bit. We, on the other hand, have not resisted the winds, but have always bent with them. We recognized the superior power of the wind and so, the harder the wind blew the more we humbled ourselves before it."

Always remember to bend with the wind, and you won't be blown over by the storm!

Emedinews:Insights on Medicolegal issues:Law and Injury in medico legal cases

Injury, assault and hurt are terms invariable used by doctors in hospital practice, often as synonyms. But all these three words have different meaning in law. They have been defined by the Indian Penal Code as below.

·         Injury Section, 44 IPC defines injury- Any harm whatever illegally caused to any person in body, mind, reputation or property

·         Assault Section 351 IPC defines assault as an offer or threat or attempt to apply force on body of another in a hostile manner. It may be a common/simple assault or an intention to murder.

·         Hurt: Section 319 IPC defines hurt as Whoever causes bodily pain, disease or infirmity to any person is said to cause hurt.

The cases of Hurt/body injury that we as doctors we deal with mean bodily pain, wound, disease or infirmity voluntarily caused to any person in medicolegal cases. This would include abrasions, contusions, lacerations, stab wounds, electric shock, fire arm or ligatures etc resulting in human body injury. The doctor who is certifying an injury report should keep in mind the Penal provision, which is required by police to book the case e.g. Simple Injury: Section 323 IPC, Simple injury caused by dangerous weapons: Section 324 IPC, Grievous Injury: Section 325 IPC, Grievous injury caused by dangerous weapons: Section 326 IPC, Dangerous Injury: Section 307 IPC, Injury likely to cause death: Section 304 IPC, Injury sufficient to cause death: Section 302 IPC and causing hurt by means of poison: Section 328 IPC

Emedinews:Makesure: A patient with ejection fraction of 20% dies a sudden cardiac death.

Situation: A patient with ejection fraction of 20% dies a sudden cardiac death.
Reaction: Oh my God! Why was an ICD not put?
Lesson: Make sure all patients with ejection fraction less than 35% are put on ICD unless contraindicated.