Assessment of the severity of the condition of patients in the provision of emergency therapeutic and surgical medical care at the prehospital stage.
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44.Miranda, D.R. Therapeutic intervention scoring system: The TISS-28 items — results from a multicenter study / D.R. Miranda, A. de Rijk, W. Schaufeli // Crit Care Med. — 1996. — № 24. — P. 64–73.
45.Oostenbrink, R. Prediction of bacterial meningitis in children with meningeal signs: reduction of lumbar punctures / R. Oostenbrink, K.G.M. Moons // Acta Paediatrica. — 2001. — № 90. — P. 611–617.
46.Oostenbrink, R. Children with meningeal signs. Predicting who needs empiric antibiotic treatment / R. Oostenbrink, K.G.M. Moons // Arch Pediatr Adolesc Med. — 2002. — № 156. — P. 1189–1194.
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50.Simpson, D. Pediatric coma scale / D. Simpson, P. Reilly // Lancet. — 1982. — № 2. — P. 450.
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APPENDIX
Types of legal liability when providing medical care
There are the following types of legal liability:
–administrative;
–disciplinary;
–civil;
–criminal.
Moral responsibility (ethical) does not formally relate to problems of law, but, of course, is directly related to them.
Administrative responsibility.
Administrative offenses are an area of administrative law, a branch of jurisprudence that regulates the scope of activities of executive authorities in the proper execution of the requirements of the state and municipal authorities. Administrative responsibility relates primarily to health authorities rather than to medical professionals. Administrative liability is regulated by the Code of the Russian Federation on Administrative Offences.
Disciplinary responsibility.
Disciplinary liability relates to labor legislation and provides for punishment for violation by an employee of his labor duties. Such violations include failure to comply with internal regulations, absenteeism and systematic absence from work without a good reason, appearing at the workplace while intoxicated, theft of property, etc. Disciplinary liability is regulated by the Labor Code of the Russian Federation. Disciplinary measures: reprimands, reprimands, dismissal.
Civil liability is regulated by the Civil Code (Civil Code) of the Russian Federation. Civil, or civil liability, is a type of legal liability in which sanctions established by law or contract are applied to the offender. These measures include compensation for losses, payment of penalties, fines, penalties, compensation for moral and other damage caused. Civil liability applies not only to individuals (medical workers), but also to legal entities (medical institutions). In accordance with Article 1068 of the Civil Code of the Russian Federation, a medical institution (legal entity) compensates for harm caused by its employees. After compensation for material damage to the patient or his heirs, the institution may, in a recourse procedure, demand compensation for damage from the employee responsible for causing the damage. The scope and nature of compensation for harm caused by damage to the health of a citizen is described in Article 1085 of the Civil Code: the patient must be compensated for the
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earnings (income) lost by the patient, and expenses for treatment, additional food, care, sanatorium treatment, prosthetics, purchase of special transport, retraining for another profession, etc. The procedure for calculating the lost income of an injured patient is clearly defined in Article 1086 Civil Code.
Criminal liability is regulated by the Criminal Code (CC) of the Russian Federation. In accordance with Article 8 of the Criminal Code, the basis for bringing citizens to criminal liability “is the commission of an act containing all the elements of a crime provided for by this Code.” The most common articles of the Criminal Code of the Russian Federation used in the practice of doctors, including anesthesiologists, are as follows.
Article 26 “Crime committed through negligence”.
A crime committed through negligence is an act committed through thoughtlessness or negligence.
A crime is recognized as committed due to frivolity if a person foresaw the possibility of socially dangerous consequences of his actions (inaction), but without sufficient grounds, he arrogantly hoped to prevent these consequences.
A crime is considered committed through negligence if a person did not foresee the possibility of socially dangerous consequences of his actions (inaction), although, if necessary and foresighted, he should and could have foreseen these consequences.
Causing harm to the health of the patient
The occurrence of complications during diagnosis, treatment and rehabilitation, anesthesia, resulting in severe or moderate harm to the patient’s health is classified according to Article 118 of the Criminal Code of the Russian Federation, which describes circumstances that are often encountered in medical practice and fit the description Article 26 of the Criminal Code of the Russian Federation, stated above. Causing death by negligence is determined by the conditions described in Article 109 of the Criminal Code of the Russian Federation, containing signs of negligence or arrogance, discussed in Article 26 of the Criminal Code of the Russian Federation
“Crime committed through negligence” (see above).
The next most frequently used article in medical practice is Article 124 of the
Criminal Code of the Russian Federation “Failure to provide assistance to a patient.”
Article 293 “Negligence” has clause 2, which describes death by negligence due to improper performance of duties by an official. This article can hardly be applied to a doctor working with a patient in a ward, operating room, etc. It refers to officials who are obliged to ensure normal conditions for the provision of medical care. According to Yu.D. Sergeev, officials are considered to be employees who permanently or temporarily perform the functions of government representatives and have organizational, managerial and administrative responsibilities.
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Officials in medicine — chief doctors and their deputies, heads of departments, employees of health authorities, etc.
Moral and legal problems arising at the stage of providing medical care in
ahospital:
–iatrogenic damage is an urgent problem in critical medicine;
–protection of patients' rights in extreme conditions;
–moral and legal aspects of complications;
–legal qualification of an accident, medical error;
–protection of the rights of anesthesiologists and anesthetists;
–legal culture of an anesthesiologist.
Iatrogenic damages — an current problem of critical medicine
The methods used in medicine are becoming more and more invasive, and medicine itself is becoming more and more aggressive. In carrying out this aggression, medicine has good intentions: to reduce the number of patients who were incurable in the recent past, to penetrate into previously inaccessible areas of the body, but all this happens under the protection of anesthesiology and intensive care, including the artificial replacement of many vital functions.
Terminology.
Iatrogenesis (from the Greek ιατροσ — doctor and γενεα — give birth) refers to diseases or injuries that arise from the actions of a doctor.
Classification of iatrogenic injuries.
Iatrogenic injuries in anesthesiology can traditionally be divided into three groups:
1.Associated with diagnostic procedures: instrumental damage from bronchoscopes and other diagnostic devices, radiation damage during X-ray and radiological studies, allergic and toxic reactions to contrast agents and test drugs.
2.Associated with therapeutic actions: overdose of anesthetics and other drugs, allergic reactions to medications, including drug anaphylactic shock (in anesthesiology, about 70 % of drug shocks are caused by muscle relaxants), puncture, injection, infusion, intubation and many other damage to organs and functional systems, operating room stress and mechanical damage to organs during surgery and aggressive procedures.
3.Associated with psychological defects: insufficient psychological contact with the patient; lack of agreement on the types and volume of treatment with the patient or his representatives; Intensive care unit (ICU) syndrome.
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Pathogenetic classification.
Iatrogenic pathology occurs in connection with one of three effects or their complex:
1)the inevitable effect of the method itself (for example, every operation causes operational stress, every massive infusion damages the lungs, the blood system, every resuscitation causes reperfusion damage, etc.);
2)the effect of an excessive dose or regimen (including underestimation of the patient’s individual sensitivity);
3)the influence of procedural errors (for example, insertion of an endotracheal tube into the esophagus, mechanical damage to the pharynx, etc.).
In a number of cases, iatrogenicity can be assessed as unintentional harm to health using the relevant articles of the Civil Code of the Russian Federation (Articles 503, 732, 737, 739, 783, 1064, 1067, 1073, 1074, 1083) and the Criminal Code of the Russian Federation (Articles 26, 28, 41, 109, 118).
Protecting patients' rights
Fundamental rights of patients in the form as they are summarized in Article 30
“Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens”.
Article 30 “Patient's rights”. When seeking and receiving medical care, the patient has the right to:
–respectful and humane attitude on the part of medical and service personnel;
–choosing a doctor, including a family and attending physician, taking into account his consent, as well as choosing a medical institution in accordance with compulsory and voluntary health insurance contracts;
–examination and treatment, stay in conditions that meet sanitary and hygienic requirements;
–holding, at his request, a council and consultations of other specialists;
–relief of pain associated with the disease and/or medical intervention, using available methods and means; maintaining confidentiality of information about the fact of seeking medical help, about the state of health, diagnosis and other information obtained during his examination and treatment, in accordance with Article 61 real “Fundamentals”;
–informed voluntary consent to medical intervention in accordance with Article 32 real “Fundamentals”;
–refusal of medical intervention in accordance with Article 33 real “Fundamentals”;
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–obtaining information about your rights and obligations and health status in accordance with Article 31 of these “Fundamentals”, as well as the choice of persons to whom, in the interests of the patient, information about the state of his health can be transferred;
–receiving medical and other services within the framework of voluntary health insurance programs;
–compensation for damage in accordance with Article 68 of these “Fundamentals” in the event of harm to his health during the provision of medical care;
–access to a lawyer or other legal representative to protect his rights;
–admission to a clergyman, and in a hospital institution — to provide conditions for the performance of religious rites, including the provision of a separate room, if this does not violate the internal regulations of the hospital institution.
In case of violation of the patient's rights, he can file a complaint directly with the head or other official of the medical institution in which he received medical care, with the relevant professional medical associations and licensing commissions, or with the court.
Regulatory framework
1.November 21, 2011, № 323-FZ Russian Federation “Federal law on the fundamentals of protecting the health of citizens in the Russian Federation”. Adopted by the State Duma on November 1, 2011. Approved by the Federation Council.
2.Order of the Ministry of Healthcare of Russia dated June 20, 2013, № 388n (as amended on February 21, 2020) “On approval of the Procedure for the provision of emergency, including specialized emergency medical care” (registered with the Ministry of Justice of Russia on August 16, 2013, № 29422).
3.Order of the Ministry of Healthcare of the Russian Federation of November 15, 2012, № 926n “On approval of the Procedure for providing medical care to the adult population for diseases of the nervous system” (registered with the Ministry of Justice of the Russian Federation on January 23, 2013).
4.Order of the Ministry of Healthcare of the Russian Federation dated November 15, 2012, № 916n “On approval of the Procedure for providing medical care to the population in the field of pulmonology” (with amendments and additions dated
February 21, 2020).
5.Order of the Ministry of Healthcare of the Russian Federation dated November 15, 2012, № 918n “On approval of the Procedure for providing medical care to patients with cardiovascular diseases” (as amended and supplemented: April 14,
2014, February 22, 2019, February 21, 2020).
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6. Order of the Ministry of Healthcare of the Russian Federation of November 12, 2012, № 901n “On approval of the Procedure for providing medical care to the population in the profile of «traumatology and orthopedics»” (with amendments and additions dated February 21, 2020).
7.Decree of the Government of the Russian Federation of September 20, 2012,
№950 “On approval of the Rules for determining the moment of death of a person, including the criteria and procedure for establishing the death of a person, the Rules for terminating resuscitation measures and the form of the protocol for establishing the death of a person”.
8.Standard of emergency medical care for acute respiratory failure. Approved by Order Ministry of Healthcare of the Russian Federation dated July 5, 2012,
№458n.
9.Standard of emergency medical care for status asthmaticus. Approved by Order Ministry of Healthcare of the Russian Federation dated December 20, 2012,
№1087n (registered with the Ministry of Justice of the Russian Federation on March 15, 2013, № 27698).
10.Standard of emergency medical care for children with asthma. Approved by the Order of the Ministry of Healthcare of the Russian Federation № 1119n dated December 20, 2012 (registered with the Ministry of Justice of the Russian Federation on March 1, 2013, № 27422).
11.Standard of emergency medical care for asthma. Approved by Order of the Ministry of Healthcare of the Russian Federation of December 20, 2012, № 1086n (registered with the Ministry of Justice of the Russian Federation on January 22, 2013, № 26657).
12.Standard of emergency medical care for asphyxia. Approved by Order of the Ministry of Healthcare of the Russian Federation dated December 24, 2012,
№1429n (registered with the Ministry of Justice of the Russian Federation on March 20, 2013, № 27797).
13.Standard of emergency medical care for pneumonia. Approved by Order of the Ministry of Healthcare of Russia dated December 24, 2012, № 1437n (registered with the Ministry of Justice of Russia on February 25, 2013, № 27298).
14.Standard of emergency medical care for pulmonary embolism. Approved by Order of the Ministry of Healthcare of Russia dated December 20, 2012, № 1126n (registered with the Ministry of Justice of Russia on February 13, 2013, № 27047).
15.Standard of emergency medical care for spontaneous tension pneumothorax. Approved by Order of the Ministry of Healthcare of Russia dated December 24, 2012, № 1407n (registered with the Ministry of Justice of Russia on March 6, 2013,
№27541).
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16.Standard of specialized medical care for pulmonary embolism. Approved by Order of the Ministry of Healthcare of the Russian Federation dated November 9, 2012, № 873n (registered with the Ministry of Justice of Russia on February 13, 2013, № 27059).
17.Standard of specialized medical care for bronchiectasis. Approved by Order of the Ministry of Healthcare of Russia dated December 28, 2012, № 1596n (registered with the Ministry of Justice of Russia on March 6, 2013, № 27521).
18.Standard of specialized medical care for pleurisy. Approved by Order of the Ministry of Healthcare of Russia dated December 29, 2012, № 1658n (registered with the Ministry of Justice of Russia on February 13, 2013, № 27769).
19.Standard of specialized medical care for pneumonia of moderate severity. Approved by Order of the Ministry of Healthcare of Russia dated December 29, 2012, № 1658n (registered with the Ministry of Justice of Russia on February 13, 2013, № 27046).
20.Standard of primary health care for ventricular tachycardia. Approved by Order of the Ministry of Healthcare of Russia dated November 9, 2012, № 787n (registered with the Ministry of Justice of Russia on January 22, 2013, № 26660).
21.Standard of specialized medical care for ventricular tachycardia. Approved by Order of the Ministry of Healthcare of Russia dated November 9, 2012, № 710n (registered with the Ministry of Justice of Russia on February 5, 2013, № 26826).
22.Standard of primary health care for supraventricular tachycardia. Approved by Order of the Ministry of Healthcare of Russia dated November 9, 2012, № 711n (registered with the Ministry of Justice of Russia on December 29, 2012, № 26487).
23.Standard of emergency medical care for acute coronary syndrome without ST segment elevation. Approved by Order of the Ministry of Healthcare of Russia dated July 5, 2016, № 456n (registered with the Ministry of Justice of Russia on July 18, 2016, № 42894).
24.Standard of emergency medical care for acute coronary syndrome with ST segment elevation. Approved by Order of the Ministry of Healthcare of Russia dated December 24, 2012, № 1383n (registered with the Ministry of Justice of Russia on January 21, 2013, № 26639).
25.Standard of emergency medical care for diseases characterized by high blood pressure. Approved by order of the Ministry of Healthcare of Russia dated December 24, 2012, № 1513n (registered with the Ministry of Justice of Russia on February 27, 2013, № 27355).
26.Standard of emergency medical care for cardiogenic shock. Approved by Order of the Ministry of Healthcare of Russia dated December 24, 2012, № 1432n (registered with the Ministry of Justice of Russia on March 26, 2013, № 27897).
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27.Standard of emergency medical care for aortic dissection. Approved by Order of the Ministry of Healthcare of Russia dated December 24, 2012, № 1442n (registered with the Ministry of Justice of Russia on March 12, 2013, № 27625).
28.Standard of emergency medical care for heart failure. Approved by Order of the Ministry of Healthcare of Russia dated July 5, 2016, № 460n (registered with the Ministry of Justice of Russia on July 15, 2016, № 42871).
29.Standard of specialized medical care for heart failure. Approved by Order of the Ministry of Healthcare of Russia dated December 24, 2012, № 1554n (as amended on April 20, 2022) (registered with the Ministry of Justice of Russia on March 20, 2013, № 27789).
30.Standard for specialized medical care for atrial fibrillation and flutter. Approved by Order of the Ministry of Healthcare of Russia dated December 28, 2012,
№1622n (registered with the Ministry of Justice of Russia on March 22, 2013,
№27846).
31.The procedure for providing medical care to patients with acute cerebrovascular accidents. Approved by Order of the Ministry of Healthcare of Russia dated November 15, 2012, № 928n (as amended on February 21, 2020) (registered with the Ministry of Justice of Russia on February 27, 2013, № 27353).
32.Standard of emergency medical care for children with unspecified meningococcal infection. Approved by Order of the Ministry of Healthcare of Russia dated December 24, 2012, № 1444n (registered with the Ministry of Justice of Russia on February 14, 2013, № 27078).
33.Standard of primary health care for generalized epilepsy. Approved by Order of the Ministry of Healthcare of Russia dated December 24, 2012, № 1439n (registered with the Ministry of Justice of Russia on March 13, 2013, № 27631).
34.Standard of specialized medical care for intracerebral hemorrhage (conservative treatment). Approved by Order of the Ministry of Healthcare of Russia dated December 29, 2012, № 1692n (registered with the Ministry of Justice of Russia on March 22, 2013, № 27838).
35.Standard of specialized medical care for injuries of the spine, spinal cord and spinal cord nerves. Approved by Order of the Ministry of Healthcare of Russia dated November 7, 2012, № 639n (registered with the Ministry of Justice of Russia on February 7, 2013, № 26908).
36.Standard of specialized medical care for epilepsy. Approved by Order of the Ministry of Healthcare of Russia dated December 24, 2012, № 1541n (registered with the Ministry of Justice of Russia on March 5, 2013, № 27456).
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37.Standard of specialized medical care for children with epilepsy. Approved by Order of the Ministry of Healthcare of Russia dated December 29, 2012, № 1695n (registered with the Ministry of Justice of Russia on March 21, 2013, № 27822).
38.Standard of specialized medical care for cerebral infarction. Approved by Order of the Ministry of Healthcare of Russia dated December 29, 2012, № 1740n (registered with the Ministry of Justice of Russia on March 5, 2013, № 27483).
39.Standard of specialized medical care for transient ischemic attack. Approved by Order of the Ministry of Healthcare of Russia dated December 29, 2012,
№ 1693n (registered with the Ministry of Justice of Russia on April 4, 2013,
№27985).
40.Standard of specialized medical care for lesions of individual nerves, nerve roots and plexuses. Approved by Order of the Ministry of Healthcare of Russia dated November 7, 2012, № 616n (registered with the Ministry of Justice of Russia on January 21, 2013, № 26618).
41.Order of the Ministry of Healthcare of the Russian Federation dated October 28, 2020, № 1165n “On approval of requirements for the provision of medicines and medical devices for equipment and kits for the provision of emergency medical care”.
42.Clinical recommendations “Emergency medical care”. Edited by Academician of the Russian Academy of Sciences S.F. Bagnenko. Moscow: GEOTAR-media, 2020.
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