Maxillofacial Surgeon as Fact Witness for Medico-Legal Cases: Indian Scenario

Abstract

An Oral and Maxillofacial surgeon at any time during the practice will encounter medicolegal cases (MLC). There are lacunae in the knowledge and understanding of the correct method of dealing with such cases. Many of the practitioners are apprehensive and anxious as they have to interact with individuals and systems outside the normal realm of practice. In today’s arena, it is of utmost importance to be aware of legal system and law of the land. An OMF surgeon needs to have thorough understanding in recording and maintenance of the details of all MLCs and presenting the same in the court. Professional guidelines for expert witness are often not well recognised as those relating to the clinical practice. Surgeon has an obligation to conduct him/herself to highest ethical standards. This article provides insight into the details of registration of MLC, examination and recording of injuries, collecting medico-legal evidences and writing a medico legal report. Also discusses the court proceedings and possible questions that may be faced by the surgeon in the court.

Medico-Legal Case

A medico-legal case is a case of injury or illness where the attending doctor, after eliciting history and examining the patient, thinks that some investigation by the law enforcement agencies is essential to establish and fix responsibilities for the case in accordance with the law of the land.

The doctor can receive the medico legal cases in three ways: [1]

1. The patient reporting to the hospital after the incident.

2. Patient brought by the police for examination.

3. Patient referred from other hospital after registering the medico legal case for expert management.

At the given time, patient may or may not intend to register a medico legal case. In suspected cases it is mandatory to record them as medico legal cases (MLC) and inform the police. Request by the patient or the accompanying person not to register the MLC should not be accepted. Not informing the police of such cases may invite trouble for the doctor under Section 39 of the criminal procedure code (CrPC) [2]. In case of emergency all legal formalities stand suspended till the patient is out of danger.

Registration of a Medico-Legal Case (MLC)

The decision to register any case as a medico legal case rests solely with the doctor who attends to the case. A doctor must always exercise his judgement independently and with complete objectivity. Any requests by the relatives or friends accompanying the patient for not registering the case as MLC should not be entertained by the attending doctor.

When the patient has been referred by another hospital where a MLC has been registered, mention of the same should be made in the patient admission records. Further treatment can be carried out and a fresh registration of MLC is not required.

In cases where a MLC has not been registered in the previous hospital, a copy of the referring notes should be attached with the medico-legal report.

In general the cases to be registered as MLC are listed in Table 1. Sometimes, the patient may come or be brought for the examination several days after the event; even in such cases MLC has to be registered, examination carried out and recorded about the present clinical findings. Opinion should be given on the current status of a case.

Table 1.

Cases to be registered as medico-legal cases (MLC) in general

Road traffic and road side accidents	Burn injuries due to any cause
Accident or unusual occurrences in a factory	Suspected or evident poisoning
All cases of serious injury	Suspected or evident sexual offences
Suspected homicidal injuries	Suspected or evident child abuse
Suspected self-inflicted injuries	Suspected or evident intimate partner abuse
Suspected attempts at suicide	Cases referred by the police or a court of law for some specific legal or medico-legal requirement
Unconscious patients where the cause of unconsciousness is not clear	Cases brought dead to hospital with improper, inadequate and incomplete history

Any injury where foul play is suspected and the injured appears to be either a victim or the culprit is a criminal case

In cases where MLC is not registered initially and if a treating doctor or specialist feels that a case has to be registered as MLC, same has to be communicated with the casualty medical officer (CMO) for necessary action.

If the person’s condition is such as to endanger life, notice to this effect should be sent to the police at once, with a request that a magistrate should be summoned to take the patient’s dying declaration.

Intimation to the Police

For all the MLC that are registered, written intimation must be sent to the police station that falls in the area of jurisdiction. This duty is usually done by the CMO.

Consent for Medical Examination

Consent for medical examination should be taken in all cases. When a person is brought by the police, requisition form duly filled by the investigating officer will constitute authority for the examination and no separate consent is required for examination. The requisition form also gives a brief description of facts related to the case that will help the doctor in examination as per the requirements of a case and ultimately aids the cause of justice. The primary aim of medical examination in accused cases, at the request of the police is to record medical evidence and collect samples that might be used as evidence in a court of law. Section 53 CrPC states that medical examination of a female must be carried out either directly by or under the supervision of a female registered medical practitioner.

Preparation of Medico-Legal Report

A medico-legal examination report must be prepared on an appropriate form by an attending doctor or CMO. The report should be legible, neat and written by a doctor in his own handwriting.

A medico-legal examination report should comprise of three parts:

1. Preamble The report should mention the date, time and place of examination, and the names of the individuals, if any, who accompanied. In case a person is brought by the police, the particulars of the accompanying police official including his name, personal number, rank, and police station should be noted. A short description of the “alleged history” should be mentioned. In cases where a patient cannot give any history himself, the name and particulars of the person giving the alleged history should be mentioned.

2. Findings/observations As in all cases, examination starts with general physical examination and recording of vital parameters. The mental status and level of orientation must be mentioned. Two identification marks like scars, moles or tattoos should be noted. The report should include a full description of any injuries or other conditions found. While describing an injury its type (abrasion, contusion, laceration, stab or incised wound, etc.), its dimension (length, breadth and depth where possible) and location (position in relation to a bony point) must be mentioned. In firearm injuries, blackening tattooing or singeing should be mentioned if they are present. Their absence should also be mentioned. In cases of poisoning, description of signs and symptoms must be included. Gastric lavage should be done in cases of suspected poisoning and the same sent for chemical analysis. In case the nature of poison is not clear, a probable cause of poisoning may be mentioned. In cases where the nature of injury cannot be ascertained immediately, a patient may be admitted to hospital for observation and the same mentioned in the MLC report.

3. Opinion This includes the classification of the injuries, that is, whether simple or grevious, the nature of the weapon and any other information that may prove helpful to the police. While opining on the age of injuries, findings such as fresh haemorrhage, clot formation, colour of scab, colour changes in a healing bruise, pus formation, etc., should be taken into account. In case an opinion regarding the nature of injury cannot be given on clinical examination alone, opinion may be reserved till the receipt of X-ray or other investigation reports or till the period of observation of a patient is completed. When X-ray examination is to be carried out, radiologist should mention MLC number in the film and also in the X- ray report. Mention must be made of any material found on the body and all samples collected and sealed.

Report should be completed as early as possible after examining a person and instituting life-saving treatment where required. Two copies of a report should be prepared. The original is handed over to the police and a copy kept for reference. The reporting registered doctor/medical practitioner must sign the report, write his name and affix the official stamp .

The examination may extend to clothing, weapons, or other articles. These exhibits, as they will be called in court, should be returned to the police after examination. Examination of these articles must be confined to noting any evidence of a struggle they may present, and determining whether the weapon produced is such as could have caused the injuries.

Material evidence is evidence provided by material objects that have a substantial and relevant bearing on the decision in a case by their connection with the principle fact. In cases of assault, bloodstained or torn clothing should be preserved. Intact clothing may also be important in disproving a case of alleged assault. In many self inflicted wounds the covering clothes are often removed to expose the part fully. Dirt, mud, hair and tissues embedded in the nail beds have evidentiary value. Trace evidence from the examination and treatment may include clothes, blood stains, gastric lavage, bullets or pellets, etc. which should be properly preserved, sealed and submitted to the police after obtaining a receipt for the safe custody and further analysis by a competent authority. Mention of these trace evidences must be made in the MLC report.

Custody of the Medico-Legal Reports

All medico legal reports and related documents should be kept under the custody of the CMO till they are completed and thereafter the records section of the hospital should maintain these records which may be required for giving subsequent opinion and for production in a court of law.

In case of death of the medico-legal case in the hospital, dead body should be sent to the mortuary for post-mortem examination and intimation regarding death sent to the hospital administration and the police. A death summary should be prepared in duplicate giving all relevant details of the history, findings and management of the case. It should be handed over to the police.

All cases which are declared, brought in dead, to a hospital, must be registered as MLC. The time and date on which the person was brought must be recorded. The name of the accompanying person and a brief description of the alleged history should also be noted. The body should be sent to the mortuary for post-mortem examination and immediate intimation to the police.

Medico-Legal Aspects of Injuries

The word injury denotes any harm whatever illegally caused to any person, in body, mind, reputation or property according to Indian penal code Section 44.

Among the various aspects of injury, the nature, severity, and circumstances of an injury have great importance in criminal law. Injury can be classified in two different aspects namely legal and medico legal.

Classification as per the law

1. Simple

2. Grevious.

Medico-legal classification

1. Accidental.

2. Suicidal or self-inflicted.

3. Homicidal.

4. Fabricated.

Maxillofacial surgeon should be conversant with the following provisions of the Indian Penal Code (IPC), 1860 that have a bearing upon the legal consequences of the classification of a wound or injury into simple or grevious:-

Section 319, I.P.C—Hurt-whoever causes bodily pain, disease or infirmity to any person is said to cause hurt.

Section 320, I.P.C—Grevious hurt-the following kinds of hurt only are designated as grevious:

Firstly-Emasculation

The provisions of this clause apply only to males. Infliction might be by either sex. It implies a loss of virility or loss of sexual power.

Secondly-Permanent Privation of the Sight of Either Eye

Loss of eyesight in the affected eye has to be of a permanent nature. This injury is grevious not only because it deprives a person of the organ of sight, thus severely affecting his quality of life, but also because of the disfigurement it produces.

Thirdly-Permanent Privation of the Hearing of Either Ear

Deafness as a result of injury has to be of a permanent nature. The degree of loss of hearing may be either partial or complete. It may be correctable by surgery, but where the injury produced a permanent reduction in hearing, it is grevious.

Fourthly-Privation of any Member or Joint

The description of member in this clause includes any limb or its part, including fingers, and their parts. The limb might be lost either partially at a joint or completely. The privation must include injury of a magnitude that renders them permanently non-functional, either partially or completely.

Fifthly-Destruction or permanent impairment of the powers of any members or joint

The functional loss of a limb or its part constitutes grevious injury. The loss of function might be partial or complete.

Sixthly-Permanent Disfiguration of the Head or Face

Disfiguration means some form of facial mutilation that has the effect of altering the appearance of a person. It is different from disability, in that there might not be any loss of function or incapacitation.

Any injury that leaves a permanent scar on the face is also grevious under this clause. The possibility of correction through cosmetic surgery should not be a factor while assessing such injury. A lacerated wound over the scalp is considered as a simple injury since it does not cause cosmetic disfigurement as the part is covered by hair. A disfiguring injury in a young and unmarried female would be treated as more severe injury as it may have the effect of disablement when the quality of life is considered.

Seventhly- Fracture or Dislocation of a Bone or Tooth

The fracture of a bone or tooth is considered as grevious injury. The fracture might be visible only radiologically. It might or might not be associated with dislocation and functional impairment.

Any break in continuity of a bone or tooth that is appreciable on a radiograph can be treated as fracture. Though the fracture might affect only the outer table of bone or the cortical portion, considering the pain and disability that results from such injury to a bone or tooth it has to be regarded as a grevious injury. A tooth that has become loose for the same reason also constitutes a grevious injury.

Eighthly-Any hurt which endangers life or which causes the sufferer to be, during the space of twenty days, in severe bodily pain, or unable to follow his ordinary pursuits

There are three classes of injury that are defined as grevious hurt under this clause.

1. Endangering life- a dangerous injury can be a threat to life with possibility of death. A dangerous injury is an injury that poses an imminent or impending threat to life and is sufficient to cause death in ordinary course of nature. In declaring an injury as being dangerous, the nature, site, extent of injury, the weapon used and the body part injured should be taken into consideration. The extent of resuscitative and treatment modalities employed along with the period of hospitalization constitute a peripheral consideration.

2. Severe bodily pain for twenty days—the pain is subjective and variable. It is not possible to measure pain clinically and there is no quantum of pain defined in law. Any serious injury which may or may not pose an immediate danger to life is usually acutely painful. To describe an injury as grevious under this clause, the feeling of pain as a result of injury has to be experienced by the victim for a period of twenty days. The duration along with severity of pain has to meet the requirements of this clause.

3. Inability to follow ordinary pursuits for twenty days—as per this clause the injured person should be unable to attend to his ordinary pursuits or activities for a period of twenty days for a hurt to be called grevious. Ordinary pursuits refer to the normal daily activities of a person from the moment he wakes up in the morning till the time he retires at night. Ordinary pursuits do not refer to the duties that constitute the job of a person.

The legal importance of these eight conditions lies in the enhanced punishment that might be awarded to the person found guilty in inflicting grevious injuries as compared to the person who has inflicted a simple injury. Therefore, assessment of any injury has to conform to the stipulations of this section of the IPC which are briefly discussed.

Legal process starts almost immediately after any injury is reported to the police. The importance of an injury is directly related to its severity in the clinical practice and superficial injuries tend to receive little attention. In the MLC even the most insignificant superficial lesion might constitute important medico-legal evidence. Every injury leads to the detection of the agent or weapon that caused it. Therefore proper descriptive terms should be employed to record findings. Accuracy of terminology used is of paramount medico-legal importance. The investigating agencies or the police give due importance to the medico-legal opinion regarding an injury before deciding the provision of the IPC under which action is required to be initiated in a case. The commonest question that is asked in any injury is “is the wound homicidal, suicidal or self inflicted?”

Correct interpretation of an injury in MLC demands the highest level of objectivity, observation skill, analytical ability and integrity.

Various aspects of the injury like the nature or appearance of the wound, the number, position, direction of the wounds, the condition of the clothing and the trace evidences available including pattern of blood stains should be taken into account before answering whether the wound is homicidal, suicidal or self inflicted.

Medico-Legal Aspects of Abrasions

An abrasion is a superficial injury involving only the outer layers of the skin. It is caused by the friction or pressure between the skin and some rough object. It bleeds very slightly and heals rapidly in a few days without formation of permanent scar. Depending upon the manner in which they are caused abrasions are classified into:

Scratch or linear abrasion-which is a linear injury produced by a sharp object, such as finger nail, thorn, or pin running across the skin.

Graze or sliding abrasion-is produced when a broad surface of skin slides or scrapes against a rough surface. It is common in road traffic accidents and occurs due to horizontal or tangential friction between the epidermis and rough surface of an object, weapon or ground. The direction of injury is indicated by the serrated border initially and heaped up epithelium at the end.

Pressure abrasion-is caused by crushing of the superficial layers of the epidermis and is associated with a bruise of the surrounding area. These are the result of more or less perpendicular application of force on the body surface. Ligature mark in hanging and strangulation and teeth-bite marks are examples of pressure abrasions.

Patterned or imprint abrasions-they are caused when force is applied at or near right angles to the skin surface. They reproduce the pattern of the objects causing them. From the design imprinted on the abraded area, the weapon of offence can be identified. Examples include, abrasions caused by cycle chain, automobile grill, and tyre of an automobile.

Abrasions are generally of simple injuries and at times they may be the only external sign of a serious internal injury. Extensive abrasion is usually suggestive of an accident, while the patterned or imprint abrasion helps to know the type of weapon used. The linear or graze abrasion helps in assessing the direction of application of force and the relative position of the victim and the assailant.

Medico-Legal Aspects of Bruises or Contusions

A contusion is produced by extravasation of blood into the tissues, as a result of damage to small vessels by a blunt impact. There is no disruption in the continuity of the skin. A fresh bruise is usually tender and slightly raised above the surface of the skin. It may have definite shape, but its margin is blurred. Though the two terms are synonymous, the term contusion is at times preferred when describing this injury in internal organs.

The design on the surface of the weapon that comes into contact with the body may be imprinted on the bruise and such a bruise is called patterned bruise.

Severe contusions, whether occurring by themselves or in association with other injuries, do not usually indicate self-infliction, except in the rare cases of persons falling from heights. An individual contemplating suicide is unlikely to choose a blunt weapon to accomplish his end.

Bruises are usually accidental and are seen over bony prominences. Self inflicted bruises are rare, as their production is painful. Patterned bruising helps in identification of object or weapon. Degree of violence can be ascertained by the size of the bruise. Character and manner of injury can be assesed from the position of bruises on the victim’s body. Time of injury can be assessed by the colour changes in the bruise. Extravasation of blood in deeper tissues may take time to appear on the surface and it is desirable to re-examine the individual after 48 h, as they may not be noticed on early examination.

In cases of homicide, bruises are common and are most frequently present on the head as a result of blows with an object. They are generally accompanied by lacerated wounds, which sometimes closely resemble incised wounds, but are indistinguishable from these by their irregular edges.

Medico-Legal Aspects of Lacerations

Lacerations are tears or splits of the skin, mucous membranes, muscles or internal organs produced by application of blunt force, which crushes or starches tissue beyond the limits of their elasticity. They are caused due to impact by hard blunt objects or weapons. Lacerated wounds are usually irregular in shape and may or may not correspond with the effective part of the weapon. The margins are irregular, ragged and frequently bruised. There may be strands of bridging tissues consisting of blood vessels, nerves, elastic and connective tissue fibres across the floor. Such wounds may contain foreign matter such as dirt, sand, gravel, etc.

Lacerations are usually accidental or homicidal and are very rarely suicidal. Lacerated wounds situated on the head points to homicide where as on other parts of the body are usually of accidental. Foreign substances like dust, sand, gravel etc., on the wound can tell about causative agent and the site where the injury was sustained. Lacerated wounds produced by broken glass might be mistaken for incised wounds.

Medico-Legal Aspects of Incised Wounds

Incised wound is one produced by a sharp edged weapon, whose length on the skin is greater than its depth. The margins are well defined, cleanly cut and free from contusions and abrasions. The shape depends on the shape of blade of the weapon and floor is sharply cut without any bridging tissues in between.

The incised wounds indicate the nature of the weapon. Direction of application of force can be ascertained from tailing and bevelling. Position and character of wounds may indicate mode of production that is suicide, homicide, etc., defence cuts are found on the dorsum and palmar aspect of hands and postero-medial aspect of forearm. Fabricated incised wounds can be produced by the person on the approachable parts of the body, to bring false charge. Self inflicted wounds are usually of a lesser degree of severity.

Medico-Legal Aspects of Stab or Punctured Wounds

Stab wounds are produced by a pointed instrument, in which the depth of penetration into the body is greater than the length of the wound on the skin. A knife is the most common weapon used to produce a stab wound. Other instruments, which can cause stab wounds, are ice picks, broken glass, scissors, sword, dagger, fork, arrow, end of an iron rod, pens, etc.

Depending on the nature of injury produced, stab wounds may be penetrating wound when the weapon penetrates the surface or when it enters a body cavity such as thorax or abdomen and perforating wound when the weapon enters the body or a part of the body on one side and comes out from the other side.

Punctured wounds are seldom suicidal and when self inflicted are almost invariably situated over the heart region. The shape of the wound may indicate the type of weapon and the depth will indicate the force of penetration.

Fabricated Wounds

Fabricated wounds are by no means uncommon. They may be self-inflicted or be inflicted at the request of the recipient. The object of the fabricator is to support a false charge. The fabricator will only produce as much injury as he thinks will be enough to confirm his story, and carefully avoids doing himself any serious harm.

Incised wounds are perhaps the most common form of self inflicted injury. Such wounds are always present on the front of the body, generally on the side opposite to the hand used in inflicting them. Wounds on the face or genital organs are rarely the work of a fabricator. As the fabricator is seldom satisfied with marking a single wound, as a rule in general, such wounds are multiple and tend to run parallel to each other.

Common mistakes that are committed in the emergency department from the medico-legal view point are included in Table 2 [3]. It is of utmost importance to record the injury in detail in Medico Legal Cases. The medico legal report should be prepared as soon as possible after the examination; it should be clear and legible. Abbreviations and overwriting should be avoided. Any corrections made should be duly signed.

Table 2.

Common mistakes that are committed in the emergency department from the medico-legal view point

Inaccurate description of a wound	Failure to correlate circumstances of a case with clinical findings, before venturing to record findings resulting in incorrect description of wounds in general and firearm wounds in particular
Ignoring stains and tears in clothing. Failure to preserve clothing where required	Ignorance leading to non-recognition of signs of physical abuse of children, elderly, intimate partner or spouses
Misinterpretation of physical injuries like describing an incised wound as a laceration, or firearm entry wound as a laceration or an exit wound	Destruction of gross and trace evidences in the course of patient care

The records should be kept safe as per the institution’s rule. When the medico legal case is admitted and discharged, same should be informed to the nearest police station.

Fact witness Patient’s attorney may request for information regarding the injury. It may be an informal discussion or a request for providing copies of the treatment records. A formal information may be asked by the issue of summons.

Summons in law means an official order to appear in a court of law or authoritatively call on someone to be present as a witness in a law court.

Summons may be issued in the name of the CMO or the operating surgeon depending on the need decided by the court for the purpose of either submitting the evidence and/or for disability assessment and cross examination.

In addition, summons may compel the surgeon to bring certain documents to the court like case records, photographs, radiographs, discharge summary and disability assessment reports.

What if summons is not received or purposely avoided?

Whoever absconds in order to avoid being served with summons, notice or order, shall be punished with simple imprisonment for a term which may extend to 1–6 months, or with fine of five hundred rupees to one thousand rupees, or with both [4].

If a person intentionally omits to attend at that place of time, or departs from the place where he is bound to attend before the time at which it is lawful same punishment is applicable [5].

Can a warrant be issued if summons is not respected/received?

Yes. A warrant may be issued if the summons is not respected.

Warrant in law means: A document issued by a legal or government official authorizing the police or another body to make an arrest, search premises, or carry out some other action relating to the administration of justice.

If the person to whom summons is issued fails to appear and the summons is proved to have been duly served and no reasonable excuse is offered for such failure a warrant can be issued [6].

Preparation Before Attending the Court

OMF surgeon is expected to carry the summons issued and the identification card representing the institution/hospital to the court.

Once the summons is received patient may be recalled for a disability assessment in road traffic accident cases, which includes clinical and radiographic examination. The guidelines for disability assessment for facial injuries is not very clear and there are no quantified disability criteria for dental and maxillofacial impairment in India.

The McBrides criteria (1955) was the established reference in India till 1980 and it was replaced by the “Manual for doctors to evaluate permanent physical impairment (1981)”.

Manual for Doctors to Evaluate Permanent Physical Impairment is based on Expert Group Meeting on Disability Evaluation and National Seminar on Disability Evaluation and Dissemination, D.G.H.S—W.H.O -A.I.I.M.S, NEW DELHI -1981.

Guidelines for evaluation of physical impairment in Facial injuries considering head and neck as a unit for 100 points are mentioned in Table 3 and split up ten point formula followed for each component is detailed in Table 4. Cranial nerve disability for sensory and motor nerves are mentioned in Table 5. Guidelines for evaluation of physical impairment for Burns of Head and Neck considering head and neck as a unit for 100 points are mentioned in Table 6 and split up ten point formula followed for each component is detailed in Table 7 [7].

Table 3.

Guidelines for evaluation of physical impairment in facial injuries: head and neck as a unit—100 points

Sl no.	Component	Points
1	Scalp and vault including forehead	10
2	Eye brows right and left (5 + 5)	10
3	Eyelids right (upper 6 + lower 4)	10
	Eyelids left (upper 6 + lower 4)	10
4	Pinna right	10
	Pinna left	10
5	Nose	10
6	Middle and lower third of face (excluding nose and pinna)	30

Table 4.

Guidelines for evaluation of physical impairment in facial injuries: split up of ten point formula for each component

Sl no.	Region	Deficit	Points
1	Scalp and vault including forehead	Scalp (disfigurement alone)	2.5
		Scalp and bone	10
2	Eye brows	Part of one or both, each side	2.5
		Total loss of one or both, each side	10
3	Eye lids upper	Skin disfigurement alone, each side	1.5
		Deformity or full thickness loss, each side	6
	Eyelids lower	Skin disfigurement alone, each side	1
		Deformity or full thickness loss, each side	4
4	Pinna	Anterior or posterior skin, disfigurement alone, each side	2.5
		Deformity due to full thickness involvement of skin and cartilage without obliteration of meatus, each side	7.5
		Deformity due to full thickness involvement of skin and cartilage with obliteration of meatus, each side	10
5	Nose	Skin cover disfigurement alone	2.5
		Deformity due to full thickness involvement with both nares patent	7.5
		Full thick deformity with one nare obliterated (7.5 + 1.25)	8.75
		Full thick deformity with both nares obliterated	10
6	Middle and lower third of face	Only aesthetic loss due to soft tissue/skeletal damage	7.5
		Functional loss (with malocclusion and mastication)	22.5
		Both aesthetic and functional lossess	30

Table 5.

Cranial nerve disability

Sl no.	Nerve	Disability rate
1	Motor cranial nerves: total or partial	20 % for each nerve
2	Sensory: total or partial	10 % for each nerve
3	Optic or auditory nerves:	Unilateral	Bilateral
	Mild	20 %	30 %
	Moderate	40 %	70 %
	Severe	60 %	100 %

Table 6.

Guidelines for evaluation of physical impairment for burns of head and neck: head and neck as a unit 100 points

Sl no.	Component	Points
1	Scalp and vault including forehead	10
2	Eyebrows right and left (5 + 5)	10
3	Eyelids, right, upper 6	10
	Lower 4
	Eyelids, left, upper 6	10
	Lower 4
4	Pinna, right	10
	left	10
5	Nose	10
6	Lips upper 5	10
	Lower 5
7	Cheek and lateral area of face, right 5	10
	Left 5
8	Neck	10

Table 7.

Guidelines for evaluation of physical impairment for burns of head and neck: split up of ten point formula for each component

Sl no.	Region	Deficit	Points
1	Scalp and vault including forehead	Scalp (disfigurement alone)	2.5
		Scalp and bone	10
2	Eye brows	Part of one or both, each side	2.5
		Total loss of one or both, each side	10
3	Eye lids upper	Skin disfigurement alone, each side	1.5
		Deformity or full thickness loss, each side	6
	Eyelids lower	Skin disfigurement alone, each side	1
		Deformity or full thickness loss, each side	4
4	Pinna	Anterior or posterior skin, disfigurement alone, each side	2.5
		Deformity due to full thickness involvement of skin and cartilage without obliteration of meatus, each side	7.5
		Deformity due to full thickness involvement of skin and cartilage with obliteration of meatus, each side	10
5	Nose	Skin cover disfigurement alone	2.5
		Deformity due to full thickness involvement with both nares patent	7.5
		Full thick deformity with one nare obliterated (7.5 + 1.25)	8.75
		Full thick deformity with both nares obliterated	10
6	Cheek and lateral areas	Skin disfigurement alone	1.25
		Deformity or full thickness loss	5
7	Lips	Skin cover disfigurement, one lip alone	1.25
		Deformity or full thickness loss of one lip alone	5
		Deformity due to involvement of both lips leading to contracture of the oral opening	10
8	Neck	Skin cover disfigurement alone	2.5
		Deformity due to involvement of skin, muscles or deeper tissues	10

The surgeon may state that the injury is grievous or not, and may also elaborate on the actual disability that the defect might cause.

Documents to be submitted to the court include original case sheets with pages numbered, photographs at the time of admission and radiographs at the time of admission and recent if any. It is adviced to keep a copy of the documents to be submitted in the court for future reference.

If the document which is to be produced or delivered to a Court of Justice is intentionally omitted or lost and/if false information is furnished, the legally bound person or the institution shall be punished [8–10].

When summoned, the surgeon is obliged to be present before the court at time and date specified. Doctor may be questioned by the lawyers of the prosecution, defence or the insurance company about the nature of injury and the quantum of disability. Most of the questions framed by the advocate would be in yes or no format and the doctor needs to be specific in answering the question.

Probable Questions that may be asked include:

1. What is your qualification?

2. Have you admitted the patient? If not who was the admitting doctor?

3. If you have admitted the patient, what was the day and time reported? What was the complaint on admission? What were your observations?

4. Do you have MLC record/maintain such records in your hospital?

5. Did you inform the police on patient admission?

6. Are you aware that you are supposed to inform the police?

7. What were your observations about the patient?

8. What was the nature of injury?

9. Was surgery required for such injury? When was it done?

10. What is the percentage of disability? What is the basis for such a percentage?

11. Have you created the documents to benefit the patient?

Doctor has to be truthful and needs to only mention the facts that have already been reported in the case sheets, wound certificate, discharge summary and disability assessment certificates. Doctor should remain non-committal about subjects that he/she is not sure about.

It is important to collect the acknowledgement for the documents submitted and court attendance certificate.

The case may be revisited and the surgeon may be called upon if the jury finds it necessary.

Conclusion

Dental jurisprudence is interesting and serious. Correct interpretation of an injury in MLC demands the highest level of objectivity, observation skill, analytical ability and integrity. The OMF surgeon should have an understanding of the law and legal system and can be a good witness as one advocates the cause of justice by presenting the truth without breaching the ethical standards.