This document discusses informed consent requirements for emergency medical treatment in both California and Australia. Under EMTALA in California, hospitals are required to provide emergency care regardless of a patient's ability to pay. Informed consent is presumed in emergency situations but full disclosure is not required if it poses a serious threat to the patient. Australian law similarly requires consent based on a practitioner's advice, with next of kin decisions or the Guardianship Tribunal ruling in the patient's best interests if incapacitated and not an emergency. The document also provides an overview of Australian medical training pathways and the 5-year orthopaedic surgery training program.

1. Consent in Trauma
And orthopaedics in Australia
Brooke Sachs 2014

2. Today’s presentation
• Case
• Questions
• Current literature
• What do you do? Californian law
• What do you do? Australian law
• Research gaps
• Australian medical training
• The Australian orthopaedic program

3. Mr Unknown
• Arrived at UC-Hillcrest with no wallet or identifying
information
• No contactable family for 24/24
• Neurosurgical issues
• Multiple orthopaedic injuries (only one ?open joint)
• In need of emergent treatment

4. How far should you go?
EMTALA
• Required to give care to patients with emergent health
conditions, regardless of capacity to pay or insurance status
• Acute SSx that could place the health of the individual in serious
jeopardy
• Serious impairments to bodily functions
• Serious dysfunction of any bodily organ/part
• Screening includes lab tests, CT scans, specialist consultations
• If on-call physician doesn’t have the specialist skills required for
an emergent condition (e.g. knee surgeon on call and spine
surgery required), it is the physician’s responsibility to ensure the
appropriate physician is contacted
• Patients can only be transferred to alternate facilities if that will
provide a higher level of care with departments not available at
the current facility
Zibulewsky J. The Emergency Medical Treatment and Active Labor Act (EMTALA) and what it means for physicians. Proc

5. Informed consent
• Patient to have a “reasonable knowledge of the procedure to
be performed as well as some understanding of the nature of
the risks involved in the procedure.” * Involving:
• Diagnosis, and steps required to determine it
• Proposed treatment including risks and chance of success
• Medically recognised (evidence- or eminence-based) alternatives
and why they are less desirable
• Consequences of declining treatment
• Full disclosure not required if that disclosure would pose a
serious threat to a patient’s wellbeing
• In emergencies, patient consent is presumed to exist for
medical treatments that address the emergency
• The case of Barnett vs Bacharach
* Hartman KM, Liang BA. Exceptions to Informed Consent in Emergency Medicine. Perspectives in Legal
Medicine and Health Law. Mar 99. http://www.turner-white.com/pdf/hp_mar99_emergmed.pdf

6. Consent: In Australia
• Similar processes and requirements to the US
• No such term as “informed consent” as it is difficult for most
in the general population to understand medical reasoning.
Considered more to consent based on the advice of a
practitioner
• If patient deemed to be incapacitated, and not an emergency,
decisions are referred to next of kin. If no next of kin or
concern about the strength of that relationship, decisions are
made by the Guardianship Tribunal in the best interests of the
patient
• Consent can be oral but it is a good idea to thoroughly
document any conversations (most hospitals have forms).
Similarly, refusal of treatment should be documented in
writing for medicolegal purposes
NSW Health. Policy Directive: Consent for treatment – Patient information. Jan 2005.
http://www0.health.nsw.gov.au/policies/PD/2005/pdf/PD2005_406.pdf

7. Australian Medical Training
High School
Undergraduate
studies
Post-grad entry
medical school
(MBBS or MD)
Internship (PGY
1)
Residency (PGY
2)
Senior Resident
Medical Officer
(PGY 3)
Unaccredited
surgeon
year/research
SET program (5
years)
Fellowship (1-2
years)
Junior Consultant
position ~
Attending
Undergraduate
medical school
Eligible to apply for pathologist training
Eligible to apply for general practice
Eligible to apply for general
surgery/medicine programs

8. The training program
• Five years
• Location-based by state, or in NSW, by North/South/Newcastle
• 6-month rotations in rural and urban/per-iurban hospitals
• Rotations in upper limb, spine, hips, knees and ankles, paediatrics,
oncology
• Syed S, Mirza AH, Ali A. A Comparison of Orthopaedic Training in
English-Speaking Countries. Ann R Coll Surg Engl. 2009 April; 91(3):
226-231/ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2765011/
• Day-Thompson R. So you want to be a surgeon…down under? BMJ
Feb 13 2008. http://careers.bmj.com/careers/advice/view-
article.html?id=2773