Medical Legal Demonstrative Evidence

The Circulatory System

2012-01-18T15:54:00.007-05:00

I received a call last week from a client who wanted to know which side of the neck contained the carotid artery and which side contained the jugular vein. I was a bit shocked at first but after giving it some thought I have realized that, although my clients are highly educated, their expertise is in a completely different area. Some things that I consider common knowledge may be completely unknown to those who missed it in high school biology class and haven’t come across it since. Therefore, I think it might be helpful for me to offer a basic primer on some of the major anatomy and physiology concepts in these blog posts I write each month. Today, in honor of that client who was trying to find the carotid artery, I’ll cover the basics of the circulatory system.

The circulator system (cardiovascular system) is easiest to understand if you divide the structures into three groups: 1) the heart, 2) the great vessels, and 3) the peripheral vessels. But overall, we must first understand that the circulatory system is a transportation system like a series of highways and smaller rural roads that act together to provide oxygen and nutrients to the various tissues of the body and to carry away waste materials and toxins. I will use this transportation and roads analogy extensively throughout this primer. I use this analogy rather than a similar analogy based on rivers or house plumbing because roads allow traffic in both directions. Arteries, which carry blood from the heart out to the body, and veins, which carry blood from the body back to the heart, often run together side-by-side, just like the north and southbound lanes of traffic on a highway.

The heart is a fist sized muscular organ that pumps the blood throughout the circulatory system. The heart is divided into four hollow chambers, two on the right and two on the left. The two upper chambers of the heart are called atria (singular, atrium). The two lower chambers are called ventricles (singular, ventricle). All blood enters the heart through the atria. The deoxygenated blood carrying waste carbon dioxide enters the right atrium through the superior vena cava and inferior vena cava, the largest veins of the body. Freshly oxygenated blood arrives into the left atrium from the lungs via the pulmonary veins. These atria are relatively thin walled without much muscle and their only task is to pump the blood that they receive from the veins down into the ventricles below. The ventricles are responsible for the major pumping action of the blood and therefore have much thicker muscular walls. The right ventricle pumps blood out to the lungs via the pulmonary arteries where the blood can release the built up waste carbon dioxide and take on the all-important oxygen in a process called gas exchange. The left ventricle pumps blood out through the aorta that, through the variety of branches and divisions we will describe below, will reach all regions of the body from the top of the head down to the bottom of the feet.

The great vessels are the major arteries and veins that connect directly to the heart. Each of the great vessels is unique so some memorization is required but there are only a few so we should be able to cover them quickly. Let’s start with the arteries. As I mentioned above, arteries carry blood away from the heart. The aorta is the largest artery in the body since it is the major highway for blood flowing to all regions of the body. It is easily recognized because it arises from the top of the heart, forms a large loop (the aortic arch), and courses down behind the heart and down through the midline of the chest and abdomen. The aortic arch has three large branches in the upper chest; the brachiocephalic artery, the left common carotid artery and the left subclavian artery. The brachiocephalic, which courses upward and to the right soon divides into the right subclavian artery and right common carotid artery. As the aorta courses down through the back of the abdomen, it has a number of branches that vascularize the abdominal organs and spine. Low in the abdomen the aorta divides (bifurcates) into the left and right iliac arteries that course down through the pelvis and into the legs. Another artery that arises from the top of the heart is the pulmonary trunk that bifurcates into right and left pulmonary arteries that send blood out to the lungs. This division of the pulmonary trunk forms a capital T shape and lies just beneath the aortic arch. The great veins include the superior vena cava, inferior vena cava and the pulmonary veins. All blood returning to the heart from the arms, upper torso, head and neck enter the superior vena cava from the right and left jugular veins and the right and left subclavian veins via the right and left brachiocephalic veins. The blood returning from the lower body enters the inferior vena cava that runs alongside the distal aorta in the back of the abdomen. Four separate pulmonary veins provide blood flow from the lungs into the posterior aspect of the left atrium.

The peripheral vessels are a bit easier to recognize and remember because many of the peripheral arteries and veins have an adjacent course (like north and southbound traffic) and have identical names. This is true for the iliac, femoral and popliteal arteries and veins in the legs, the subclavian, brachial, radial and ulnar arteries and veins in the arms and the carotid arteries and jugular veins in the neck. What confuses many is the fact that many of these different vessels are actually just the same continuous structure that has different names depending on the location. Think of a street that changes names for no apparent reason when you go through an intersection. The subclavian artery becomes the brachial artery when it passes from the chest into the upper arm and then becomes the ulnar artery after the radial artery branches off in the elbow region. Also it is good to remember that, except for the vessels of the chest and abdomen, all vessels are symmetrical with the exact same structure in each arm, each leg and on each side of the head and neck.

As with the skeleton and the various muscles, the circulatory system can be intimidating simply because of the vast number of structures and multiple names for each. The good thing is that few need to remember each and every structure to understand the system as a whole. You can always refer back to illustrations and diagrams to find the exact location or name of each vessel, but it is good to retain a working knowledge of how the blood is pumped by the heart, taken out to the body via the arteries and returned to the heart via the veins.

Infections During Pregnancy

2011-12-14T11:41:00.003-05:00

Several years ago, when my wife was pregnant with our son, I contracted a human parvovirus. Having assisted on a few cases involving gestational infections, I was quite concerned and sought treatment immediately. We also notified my wife’s obstetrician and took steps to avoid transmission of the virus to her and the developing child. Thankfully, our doctors took this situation seriously and followed us closely to be sure that there was no risk to the pregnancy. Pregnancy often leaves the mother with a weakened immune system. Infections can be a great risk to the fetus. Therefore it is an important responsibility of the obstetrician to avoid and treat infections in a timely manner.

I have participated in a variety of medical malpractice cases involving maternal infections that were not adequately treated and therefore allowed to infect the child, either in the womb or during delivery. In those cases, I have seen that there are three basic ways that the baby may become infected. 1) Congenital infections are infections that pass from the mother to the child across the placenta while the baby is womb. 2) Perinatal infections are infections of the birth canal that spread to the child during labor or delivery. These infections may cross the fetal membranes or invade after the membranes are broken to infect the baby in the womb, or infect the baby as it passes through an infected vaginal canal during delivery. 3) Postnatal infections spread to the baby after delivery, primarily through the mother’s breast milk.

Congenital infections can be caused by protozoan parasites as in toxoplasmosis, bacteria as in syphilis, or by a variety of viruses such as rubella, cytomegalovirus, herpes or human parvovirus. Each different microbe is a risk to the developing fetus at different stages of development. Some may interfere with development leading to deformities or developmental abnormalities. Others may lead to fetal death and miscarriage. It is important that the mother be monitored for infections throughout the pregnancy and that any infection be treated promptly.

Perinatal infections are caused by bacteria such as strep or viruses such as herpes or the human papilloma virus that may be present in the vagina during labor or delivery. These infections include many sexually transmitted diseases that can infect the baby during delivery. Another risk comes from fecal material that may contaminate the birth canal during labor. As mentioned above, some of these infections may cross the fetal membranes and infect the fetus in utero. Others may move into the womb after the membranes are disrupted (water breaks). Certainly the fetus is exposed to any infections within the vagina during the process of delivery as the baby passes through the birth canal. Once again, it is the responsibility of the obstetrician to recognize and treat any vaginal infections prior to delivery to avoid this contamination.

Postnatal infections involve many of the same bacteria or viruses mentioned above and can pass from the mother to the child through the breast milk. These infections can be easily avoided if the mother has been properly diagnosed and breast-feeding is delayed until after treatment is complete.

In each case of fetal infection that I’ve worked on over the years the issue being litigated is either the failure to diagnose a maternal infection or a failure to treat the infection or take steps to prevent contagion. If, in future cases, you encounter issues of fetal deformity or fetal demise, it would benefit you to do a thorough examination of the medical records to see if there is any evidence of infections that existed in the mother that may have contributed to the outcome of the pregnancy.

Intramedullary Fixation

2011-11-03T10:25:00.006-04:00

I'll never forget the first orthopedic surgery I observed while at medical school training for my medical illustration degree. I was shocked at the crude brutality of the procedure with all the hammering, sawing, drilling and reaming. It seemed more like carpentry than what I had envisioned as modern medicine. If nothing else, orthopedic surgery is certainly dramatic and perhaps this inherent drama is what makes it such a popular subject for demonstrative evidence. Because of that popularity, I have selected one orthopedic issue as our topic for the month. Let's learn a bit about intramedullary fixation.

We'll begin with the basics. When a bone is broken, the body has a remarkable ability to repair itself by producing new bone to knit the fracture back into a solid structure. This can only occur successfully if the fractured edges of bone are in contact with one another and if the fracture site is immobilized during the healing process. That is the primary goal of the orthopedist when dealing with a fracture: to align and stabilize the fracture site. In many instances, this alignment and stabilization can be done without surgery. Non-displaced fractures can be stabilized in a splint or cast. Some displaced fractures can be realigned externally before stabilization. More complex or severe fractures must be aligned surgically and held in position with fixation hardware to provide the stabilization required for healing.A variety of fixation techniques and types of fixation hardware have been developed over centuries. Orthopedic surgeons may use wires, staples, plates, screws or rods to hold fractures in position as they heal. One of the most popular techniques for fixation of large long bone (extremities) fractures is the insertion of an intramedullary rod inside the length of the bone. Long bones in the arms, legs, feet and hands consist of a hard compact outer layer that forms a tube surrounding a hollow chamber called the medullary cavity containing the bone marrow. This hollow chamber is ideal for the placement of a fixation rod allowing for the stabilization of the entire length of the bone.

The surgical technique for intramedullary fixation includes the access of the end of the broken bone through a small open incision. A hole is created through the hard outer compact bone to expose the medullary canal. A guidewire is inserted down the length of the bone to insure alignment and to identify the medullary canal. A drill-like reamer is advanced over the guidewire to clear the marrow and open a pathway for the fixation rod. Finally, the rod itself is hammered into position. Locking screws may be placed at either end of the rod to hold the rod in position. This fixation rod may be left in position permanently or may be removed at a later date following the full healing of the fracture.

Beyond the great stability offered by intramedullary fixation, there are other advantages to utilizing this technique. Intramedullary fixation can be accomplished with a much smaller incision than the large open incision required for the placement of fixation plates across the external aspect of the fracture. This reduces post-operative pain and recovery time and also involves lower risk of damage to vessels and nerves that may lie in the region of the fracture. Also, because the open incision is not at the actual site of the fracture, there is no additional disruption and risk of infection that would prevent bone healing.

Larger bones are more commonly treated with intramedullary fixation. This includes the femur (thigh), the tibia (shin) and the humerus (upper arm). Smaller bones such as the fibula (smaller lower leg bone), metacarpals (hand), metatarsals (foot), phalanges (fingers and toes) and even the clavicle (collar bone) can be fixated with smaller intramedullary rods or pins, but this is less common than the use of small plates and screws. Another term you may run across is "retrograde". Retrograde fixation means that the rod is placed through the distal end of the bone extending upward rather than into the proximal end and extending downward.

If you handle any personal injury cases in your practice, you'll eventually run across a case involving an intramedullary fixation. Hopefully this overview has helped you to better understand these dramatic orthopedic procedures.

Stations of Presentation

2011-09-29T13:42:00.007-04:00

In the past few weeks I have had calls from three attorneys with traumatic birth injury cases. Each one needed last minute help with demonstrative evidence to illustrate the basics of labor and delivery. They had all waited to the last minute, thinking they didn’t need anything very specific and that they could get something very quickly. Unfortunately, each of these clients was unable to answer one vital question about their case, which forced them to rush back to their experts for more information and nearly prevented them from acquiring their exhibits in time. The vital question they could not answer was, “What system of classification was used in this case to notate the station of presentation?”
If you’ve ever taken part in any litigation regarding labor and delivery, certainly you’re familiar with stations of presentation. Basically, this system allows the healthcare provider to record the progress the baby makes down through the birth canal during the process of labor. It is vital to chart this progress because any deviation from the normal range can give vital clues that there is a problem that might require action. Delays in fetal progress down the birth canal during labor could be a sign of a variety of problems including an insufficient size of the mother’s pelvis, inadequate contractions, shoulder dystocia or other serious complications. The records regarding this progression may be the only evidence of what was happening during labor in a case that eventually results in litigation, so the records of the fetal stations is vital. There are two separate systems in use out there and to get an accurate picture of what occurred, you must know what system was in use.

Fetal station refers to the level of the leading edge of the fetus within the birth canal (either the head in a vertex presentation, or the foot or buttocks in a breech presentation). This level is measured in relation to the location of small protrusions of the pelvis of the mother called ischial spines. The station refers to how far above or below the ischial spines the fetus has progressed. Unfortunately, there are two distinct systems for determining fetal station in use. We’ll refer to these two systems as the “thirds” system and the “fifths” system.

Traditionally, the thirds system of measuring the station of presentation was the standard. In this system the level of the birth canal level with the ischial spines is referred to as 0 station. Above the 0 station, the distance from the pelvic inlet at the top of the pelvis down to the ischial spines is divided into thirds and referred to as -3, -2 and -1 from top to bottom. Below the 0 station, the distance from the ischial spines down to the pelvic outlet where the baby emerges from the birth canal is also divided into thirds and referred to as +1, +2 and +3 as the baby progresses. So, you take the total distance between these landmarks and divide the distance into thirds.

In 1988, the American College of Obstetricians and Gynecologists began to change the system and divide these spaces into fifths. In the fifths system, the ischial spines still represent the 0 station, but the new system refers to the stations as -5, -4, -3, -2, -1, 0, +1, +2, +3, +4 and +5. More importantly, these stations are no longer just arbitrary divisions of the total space. In the fifths system each station is divided by 1 cm, so an actual measurement can be taken to more accurately determine the station, depending on how many centimeters above or below the ischial spines the leading edge has reached.

Although 0 station is the same in the thirds and fifths system, none of the other stations coincide, so it is important to know what system was used. Regretfully, no consistency is seen in the world of obstetrics and it depends on where and when the obstetrician was trained, as well as the standards of the hospital where the delivery is performed. Early in your research and discovery phase of the case, you must determine which system was in use in order to properly understand the stations that are recorded in the records. Certainly, if the time comes for you to depict the events of the case accurately in demonstrative evidence you must be sure that the illustrations you use reflect the proper system.

VBAC and Uterine Rupture

2011-06-27T15:00:00.007-04:00

Of all the issues we regularly see in OB/GYN medical malpractice cases, those involving uterine rupture are often the most devastating. The rupture of the uterus during pregnancy or during delivery can lead to severe and even fatal complications for both mother and child. Uterine rupture can result from a variety of complications, but the most common that we see is the weakening of the uterine wall caused by a previous cesarean section (C-section). These weaknesses are most apparent during an attempted vaginal birth after cesarean (VBAC) when the uterus is under extreme stress.

The uterus is a thick-walled hollow organ made up primarily of interlaced bundles of smooth muscle that give the uterus the ability to expand dramatically in size as the fetus develops and to contract forcefully to expel the fetus during delivery. In a C-section, the muscular wall of the uterus is cut creating a large opening to allow the surgeon to remove the fetus through an abdominal incision when the fetus fails to pass normally through the mother's pelvis. While this procedure provides a relatively safe and effective means of avoiding complications in the initial delivery, it can set the stage for increased complications in later pregnancies.

Following a C-section, the cut edges of the uterus are repaired with sutures and this incision site will heal over time, but this healing is accomplished with scar tissue, not new pristine muscle. This region of scar tissue at the original C-section site can never regain the full strength and flexibility of undamaged uterine tissue. In future pregnancies and particularly in future deliveries, when the uterus is again placed under stress by stretching and contracting, there is a substantial risk that there may be tearing or a complete rupture at the previous C-section site.

Risks of uterine rupture can affect both the mother and the fetus. For the mother, there is a risk of significant hemorrhage. The uterus is a highly vascular organ and tears can stretch and lacerate vessels of a variety of sizes. If not recognized and repaired promptly, these vascular injuries could prove fatal. For the fetus, there are a variety of risks. If the tear happens to compromise the placenta or major vessels supplying the uterus, there could be an interruption of umbilical blood flow leading to hypoxia or reduced oxygenation of the fetus. Also, if the rupture is of sufficient size, the fetus could be expelled out into the abdomen of the mother. This expulsion can also cause a partial or complete detachment of the placenta leading to a complete loss of blood supply to the fetus resulting in complete deoxygenation. An immediate diagnosis of the rupture and a repeat C-section would be necessary to rescue a fetus in such a case.

Years ago, VBAC was not an option. Any woman would delivered via C-section would never have been given the option of vaginal delivery in future pregnancies. Advances in surgical techniques and other medical practices have now made VBAC a viable option, but not all risks have been eliminated. The risks for a VBAC are significantly higher than for a normal vaginal birth. Such a delivery must be monitored closely and adequate facilities must be on hand and available to deal with any sudden emergencies. Any uterine rupture may result in devastating consequences for both mother and child.

Building an Attorney’s Medical Reference Library

2011-05-25T10:09:00.003-04:00

As I’ve been writing these various articles covering a wide range of medical-legal topics over the past few years, many readers have contacted me with questions regarding the references that I use. While some are interested in specific references for specific topics, I have noticed that most are just interested in building a good medical reference library for use in their practice. I believe that that is an admirable goal.

While my reference library is filled with a wide variety of anatomical atlases, cellular biology texts, chemistry texts and multiple surgical atlases, I would never dream of recommending that the average personal injury or medical malpractice attorney spend the money it would require to build such a library. I set out to try to come up with a comprehensive and affordable list and one of my first steps was to call Ms. Janabeth Evans Taylor, a widely known and respected medical-legal consultant to see if she had any recommendations. Luckily, I discovered that Janabeth has already written a great article on this topic and she has agreed to let me share it with you.

Janabeth Evans (Taylor), R.N., R.N.C., Paralegal, has been a successful medical-legal consultant since 1990. She has assisted attorneys in both state and federal court proceedings and is well recognized and highly respected for diligence, thoroughness, accuracy, and excellent communication skills. Ms. Evans (Taylor) has authored and co-developed a broad variety of publications and presentations for lawyers, paralegals and other professionals. Representative topics include medical research, internet search strategies, low speed vehicular crashes, drug litigation, soft tissue injury, placental pathology, and medical expert deposition preparation techniques.

Click here to read her excellent suggestions for Building Your Medical Library.

Custom Models for Litigation

2011-04-11T11:13:00.003-04:00

Physical models have always been popular in education. We can all remember spinning a globe to learn our geography or building a volcano to better appreciate geology. Models became even more important for me as I began a more intense study of biology and medicine. When learning the structure of molecules, there was no substitute for our little set of balls and sticks and certainly having a full size skeleton model gave a better understanding of anatomy. Medical models of all types are often very helpful in grasping concepts of structure and proximity. For these reasons, physical models also have a long history of usefulness as demonstrative evidence in trial.

Although Medical Legal Art is not in the business of creating medical models, we have always made it a practice to resell a wide range of medical models for our clients who recognize the usefulness of these items. Regretfully, until recently, I have been unaware of any company in the country that was actively creating custom models for legal use. Often clients would call and request custom models that would not only show basic normal anatomy but also be able to show the case specific facts of their case. It was frustrating to have no recommendations for these customers.

But in the past few months I've been happy to get to know the people at Archetype 3D (http://www.archetype3d.com), a company that specializes in custom models of all types. I'm thrilled that I now have a solution for those who call me requesting a source for custom models and I wanted to help them spread the news regarding their services. Click on the link below to learn more about Archetype 3D and their commitment to the use of scale models in trial. I'm sure that you will find them as pleasant as I have if you find yourself in need of custom models.

The Argument for Scale Models as Legal Props in the Courtroom

Understanding Common Ankle Fractures

2011-03-15T15:32:00.005-04:00

In honor of Ms. Marianne Clark, our Senior Account Executive here at Medical Legal Art who recently suffered a slip and fall on the ice with a resulting trimalleolar ankle fracture, I thought it apropos to dedicate this article to these common orthopedic injuries that we so often see in personal injury litigation. Ms. Clark is back in the office now recovering from her fixation surgery, but you may have noticed that I was too busy to post an article last month while she was away. It's good to have her back with us.

When involved in litigation regarding an ankle fracture, you may be confronted with terms such as medial malleolus, lateral malleolus, bimalleolar, trimalleolar and syndesmosis. It is important to understand the anatomy of the ankle before we can fully understand the terms describing the various injuries. The ankle is a joint where the tibia and fibula of the lower leg articulate with the talus bone in the upper portion of the foot. The tibia is on the medial (inner/toward the midline) aspect of the ankle and the fibula is on the lateral (outer/away from the midline) aspect of the ankle. The ends of these bones form knobs or projections that you can easily see or feel on either sides of the ankle. These protuberances are called the lateral malleolus (fibula) and the medial malleolus (tibia). Each malleolus can be fractured independently (lateral malleolus fracture, medial malleolus fracture) but if both are fractured, it is called a bimalleolar fracture. There is also a posterior projection of the tibia called the posterior malleolus. If all three regions are involved in the injury it is called a trimalleolar fracture.

The syndesmosis is the articulation between the lower portions of the tibia and fibula where they come together and touch just above the ankle joint. This articulation is held in place with a variety of ligaments and a stable syndesmosis is important for proper pain-free weight bearing. In many cases involving fractures or severe sprains of the ankle, the syndesmosis becomes separated or unstable if the ligaments are stretched or torn.

Fractures of the various malleoli can often be treated conservatively with immobilization or casting of the ankle. Internal fixation surgery is also common when metal hardware is required to secure and stabilize the fragments while the fractures heal. A variety of screws or plates and screws may be employed based on the nature of the fractures and the preferences of the surgeon. This hardware is often left in place permanently although it is not uncommon for the hardware to be removed in a subsequent procedure if it causes any difficulties after the fractures have healed. Disruptions of the syndesmosis can also be repaired surgically. These procedures can include repair or reconstruction of the ligaments or the placement of long screws that traverse both the tibia and fibula to hold the distal ends of these bones together in proper alignment.

Closed-Angle Glaucoma

2010-12-13T16:30:00.004-05:00

Several of my readers have commented that my recent topics offered nothing new to those involved daily in medically related litigation since I have been covering fairly common issues. Therefore, I've selected a topic for today's conversation that is much more rare. In twenty years of consulting in medical malpractice and personal injury cases, I have run across only a handful of closed-angle glaucoma cases. In fact, less than ten percent of all glaucoma cases in the U.S. are of the closed-angle variety.

Glaucoma is a disease involving increased pressure within the eye and is one of the leading causes of blindness worldwide. Fluid within the eye, the aqueous humor, is produced within the ciliary body behind the iris and continually flows between and iris and lens and circulates within the anterior chamber of the eye. Normally, the aqueous drains from the eye through the trabecular meshwork at the angle where the cornea and iris meet. In closed-angle glaucoma the trabecular network becomes blocked preventing proper drainage of aqueous leading to a buildup of fluid and increased pressure within the eye. If this pressure persists or increases, it can lead to permanent damage to the optic nerve.

Litigation involving closed-angle glaucoma often revolves around issues of misdiagnosis or delay in diagnosis. Patients presenting to their doctor's office or an emergency room suffering from acute closed-angle glaucoma will often have symptoms of severe eye pain, headaches, nausea, pupil dilation and distorted vision included halos or rainbows around lights at night. General practitioners or emergency room physicians do not have the tools or training necessary to correctly diagnose closed-angle glaucoma. Diagnosis can only be accomplished by an ophthalmologist who can utilize specialized instruments such as a tonometer to measure eye pressure or a gonioscope to allow for direct visualization of the angle. Prompt referral to an ophthalmologist is crucial to allow for timely diagnosis and treatment before permanent injury occurs.

In cases I have encountered, valuable time is wasted as alternate conditions are tested. Often the emergency room physician may suspect a brain injury, aneurysm or tumor based on the symptoms including the headaches and nausea. CT scans or other radiological studies may be ordered to check the brain. These studies take time allowing the pressure to continue to build within the eye. The pain in the eye may also be misdiagnosed as a more common optic condition such as conjunctivitis or corneal abrasion. In such cases eye drops may be administered to relieve the pain. These medications may provide some relief to the patient's pain but only mask the further progression of the underlying problem within the eye.

With timely referral to an ophthalmologist, closed-angle glaucoma can be diagnosed and treated promptly. Eye drops can be given initially to reduce the production of aqueous and reduce the pressure. Later, surgery will most likely be necessary to open the drainage channels at the angle. With proper treatment, the patient should have no permanent visual deficits.

Litigating Laparoscopic Surgery

2010-11-10T16:49:00.005-05:00

Laparoscopic surgery, sometimes called minimally invasive surgery (MIS), involves the insertion of a video camera and a variety of long thin surgical instruments through small "keyhole" incisions less than an inch in size. Although this technique was developed over 100 years ago, it did not gain widespread use until after the 1950's and has grown in popularity and acceptance since then. First used in only the most simple of abdominal and pelvic procedures, the complexity and variety of surgeries now performed laparoscopically have greatly expanded in recent years.

Although laparoscopic surgery has most of the same risks as traditional open surgery including possible hemorrhage or adverse reactions to anesthesia, there are many advantages that have made laparoscopic surgery popular. These benefits include reduced post-operative pain, more rapid recovery, shorter hospitalization, smaller scars and a quicker return to normal activities.

Regretfully, there are also additional risks associated with laparoscopic surgery and these risks often lie at the heart of any litigation involved. Before we discuss the risks of laparoscopic surgery, it is important to understand some of the specifics of how these surgeries are performed. At the beginning of a laparoscopic surgery, a special needle (Veress needle) is inserted into the abdomen allowing the abdominal cavity to be filled (insufflated) with CO2 gas. This creates a gas filled space in which the surgical instruments can operate. Next, after small incisions are created in the skin, sharp metal cylinders (trocars) are punched through the abdominal wall to create portals through which the laparoscope and laparoscopic instruments can be inserted. The risks associated with laparoscopic surgery that I encounter regularly are primarily associated with these initial Veress needle and trocar insertions, as well as a few other technical limitations of the laparoscopic technique.

The insertion of the Veress needle and the trocars are a risk because these sharp metal instruments are inserted blindly into the abdominal cavity. If proper procedures are followed, they are inserted into areas least likely to cause injury in a normal person, but accidents happen and procedures are not always followed, therefore these instruments can result in serious injury. Perforations of the small bowel, colon, stomach, liver or spleen can occur. Also, major arteries and veins are at risk including the aorta, inferior vena cava and iliac vessels. Perforation injuries are among the most common injuries unique to laparoscopic surgery.

Certain technical limitations also contribute to the risks of laparoscopic surgery. While traditional open incisions offer a more complete exposure and control of the surgical area, open procedures also allow the surgeon to feel the structures being manipulated. Laparoscopic surgery offers only a limited view of the operative field and none of the tactile sensation of traditional surgery. The view through the laparoscope prevents normal depth perception and provides only a view of a limited portion of the abdomen where the camera happens to be aimed at any given time. These limitations can lead to increased risks of intra-operative injury, but also can lead to a failure to recognize injuries when they occur. Whether it is a bile duct injury during laparoscopic cholecystectomy, a bowel perforation during laparoscopic hysterectomy or a vascular injury during laparoscopic sterilization, we are most often called upon to illustrate the consequences of the surgeon's failure to recognize and timely repair the damages that occur. These consequences can include peritonitis, sepsis, hemorrhage and even death and the argument is often made that the original damages would most likely have been recognized had the procedure been performed through a traditional open exposure.

Aneurysm and Dissection

2010-09-09T13:10:00.007-04:00

Arterial aneurysm and arterial dissection are two completely different conditions but both are commonly seen in medical malpractice litigation. Since an understanding of both conditions requires an overview of the circulatory system and the layers of the arterial wall, I thought it would be convenient to combine them together for today's topic.

The arteries are the blood vessels that carry blood away from the heart to the various regions of the body, unlike the veins through which blood flows back from the body to the heart. Because the blood flowing through the arteries from the heart is under pressure created by each heartbeat, the arteries are much thicker and more muscular than the veins and are able to constrict and relax when necessary to adjust the blood pressure within the body.

The layers of the wall of the arteries consist of a tough outer layer, a muscular middle layer and a thin smooth inner layer. This inner layer, the intima, plays an important role in cases of arterial dissection that we will discuss in a moment. Also, it is important to know that throughout the layers of the artery wall there is elastic connective tissue that helps the artery to resist the internal pressure and maintain its shape.

First let's discuss arterial aneurysms. An aneurysm is a weakening in the wall of an artery that allows it to bulge outward like a balloon. This weakness and loss of elasticity can be caused by a variety of factors including injury, disease, congenital malformation or prolonged increases in blood pressure. These bulging arteries can occur almost anywhere in the body but are most common in the aorta, which is the main artery that originates in the heart and courses down through the chest and abdomen, and the cerebral arteries in the head and brain. Aneurysms themselves rarely have symptoms or cause complications although large aneurysms of the cerebral arteries can cause increased pressure within the skull resulting in headaches and other neurological complaints. But aneurysms are time bombs waiting to go off. Aneurysms can rupture or burst, leading to massive hemorrhage that can result in stroke or sudden death.

Litigation regarding aneurysms usually revolves around issues of diagnosis and treatment. It is important for an aneurysm to be diagnosed prior to rupture while treatment is possible. Diagnosis can be accomplished with various radiological studies including angiograms, CT scans or MRI. Treatment usually involves surgery either by exposing and repairing the aneurysm through an open incision or by repairing it internally via catheters advanced up through the arteries (see the animation at the top of this entry). Either way, the goal is to reinforce and strengthen the wall of the vessel and to prevent a subsequent rupture.

Arterial dissections also develop from a defect in the vessel wall. A
dissection begins with a tear of the intima, inner layer, of the artery. Initially, this tear may be quite small, but over time the force of blood flow over the defect causes the torn edge to lift up and detach from the underlying layer. Over time a flap forms as the dissection continues allowing more and more of the blood to flow beneath the flap and into the space between the layers of the vessel creating a blind channel leading nowhere. Eventually the flap can become so large that normal blood flow through the vessel is blocked as the blood is channeled down beneath the intima.

Also, clotting agents within the blood will recognize the tear in the intima and accumulate at the site of injury creating a clot that can also expand causing a blockage of the vessel. Either way the resulting problem with a dissection is a severe slowing or complete blockage of blood flow that deprives the tissues and organs downstream of their normal blood supply. A dissection of a carotid artery in the neck, for example, can deprive the brain of adequate blood flow resulting in a sudden stroke, permanent brain injury or even death.

Arterial dissection can be caused by trauma including stretching of the vessel from acceleration and deceleration forces, by trauma caused during surgery by retractors or intravascular catheters, by injections or I.V. placements or by disease processes within the vasculature. Diagnosis is usually made when ischemia, or lack of blood flow, is recognized in the region supplied by the damaged vessel. Early diagnosis can permit surgical repair of the damaged vessel either by direct repair or surgical bypass.

Colon Polyps and Colon Cancer

2010-08-03T13:53:00.000-04:00

They say that things happen in clusters. I may not be superstitious or have much faith in coincidence, but I have been amazed by the number of cases I’ve seen lately involving colon polyps and colon cancer. Unlike disc herniations or brain injuries, this is not a topic we see every day, but I have certainly seen a rise in the popularity of this topic among the attorneys who call me seeking advice for medical demonstrative evidence.

As with the litigation of almost all cancer cases, colon cancer cases primarily involve issues of failure to diagnose or failure to adequately treat. More often than not, the issues revolve around the treatment, or lack there of, of colon polyps. Therefore, I offer this brief overview.

The colon, or large intestine, is the final portion of the digestive system leading ultimately to the rectum and anus. The colon is divided into segments called the cecum, ascending colon, transverse colon, descending colon and sigmoid colon. It is like a large flexible tube and normally the inner wall of the colon is smooth. For unknown reasons, some people, later in life, develop small growths on the inner wall of the colon. These growths are called polyps.

Colon polyps are not cancer, but some polyps can become cancer over time, In fact, some references state that almost all colon cancers originally begin as polyps. For this reason, it is essential for the healthcare provider to recognize, biopsy or remove polyps before colon cancer can develop.

Diagnosis of polyps can sometimes be accomplished with a barium enema, but most often the physician will perform a colonoscopy or sigmoidoscopy. A colonoscopy involves the insertion of a flexible scope through the anus that is advanced all the way around through all aspects of the colon. A sigmoidoscopy, while not as invasive as a colonoscopy, only allows the distal portions of the colon to be viewed.

With the colonoscope, a doctor is also able to completely remove or biopsy a polyp, taking a small portion for identification under a microscope. Identification is important because there are different types of polyps. Adenomatous polyps or adenoma are the most common type of polyp, but there are various types of adenomas each with a different risk of becoming cancer. Villous adenomas, while only accounting for about 15% of all polyps, carry the highest risk of becoming cancer and when diagnosed should always be removed.

In short, if a person is over 50, has a family history of polyps or colon cancer, or has other risk factors for colon cancer, they should be examined regularly to check for the presence of polyps in the colon. If polyps are found, they should be removed or followed closely by the physician to avoid the possible development of colon cancer.

Understanding Carpal Tunnel Syndrome

2010-07-01T16:42:00.010-04:00

Carpal tunnel syndrome is one of the most common and familiar medical conditions seen in personal injury litigation. Almost everyone's heard of this condition and probably knows someone who has experienced it, but over the years I've realized how poorly it is actually understood. In this article I will provide a basic appreciation of the anatomy involved in this pervasive condition, as well as an overview of the surgical procedure that often prove necessary for treatment.

First, we must recognize that the carpal tunnel really is a tunnel. It is a passageway on the palmar side of the wrist, right beneath the wrist crease where the wrist bends on the end of the arm, where the tendons the bend the fingers pass from the arm down into the hand. This tunnel is bordered by the bones of the wrist (carpal bones) on the bottom and the flexor retinaculum (transverse carpal ligament) on the top and the tendons pass through this tunnel moving back and forth as they pull and release the fingers facilitating the normal actions of the hand. Of importance we note that, along with these tendons, the median nerve also passes through the carpal tunnel. The median nerve is a major nerve that branches off of the brachial plexus in the shoulder region and courses all the way down the arm, passing through the carpal tunnel into the hand. The median nerve is responsible for innervating much of the hand including the thumb, index finger, middle finger and the inner half of the ring finger. Under normal circumstances, the median nerve is unaffected by the frequent movement of the various flexor tendons around it within the carpal tunnel.

Carpal tunnel syndrome is an assortment of symptoms resulting from compression of the median nerve within the carpal tunnel. This can involve pain, numbness, tingling and weakness of the hand or extending up the arm toward the elbow. This compression of the median nerve occurs when other structures in the carpal tunnel region (tendons, bones, flexor retinaculum or synovial linings) become inflamed and swollen and push against the other structures overfilling the space within this tunnel. This inflammation can result after injury such as strain of the tendons or fracture of the bones, or as a result of the stress caused by repetitive motions such as typing, using hand tools, playing sports or playing a musical instrument, etc. There are also certain diseases such as arthritis, diabetes, acromegaly and hypothyroidism can contribute to carpal tunnel syndrome, but these factors are not as commonly seen in litigation.

Carpal tunnel syndrome is often treated with immobilization for a few weeks with a splint or brace. Anti-inflammatory medications, such as ibuprofen, are also helpful and sometimes corticosteroid injections may be administered. But in some cases, these conservative treatments are not successful and surgery is necessary to decompress the median nerve. This surgery is called carpal tunnel release or median nerve decompression and it involves the complete transection (division) of the flexor retinaculum that forms the roof of the carpal tunnel. This surgery may be performed through an open incision or done arthroscopically with a scope and instruments inserted through much smaller incisions.

How Far Do You Want To Take Your Orthopedics Case?

2010-06-03T14:02:00.005-04:00

In personal injury litigation, orthopedics cases are generally the most straightforward. Unless there is a complex joint injury or a pre-existing condition, most laymen are going to be able to understand your average fracture case. Presentation of the injuries is usually quite straightforward as well, primarily because most orthopedics cases will have clear-cut radiological evidence: X-rays, CTs or MRIs. With such a straightforward topic and such abundant evidence and documentation, the demonstrative evidence solutions available are almost endless. The final option selected often depends on your personal preferences, presentation style, strategic priorities and budget. It comes down to, “How far do you want to take it?”

In this article I will discuss many of the various presentation options you have available to you in an orthopedics case ranging from the most simple to the most complex. I will provide the pro’s and con’s of each approach and try to provide some general ballpark figures for costs. I will also provide links to various examples so that you can better understand each option. Hopefully this will help you to decide which approach best meets your individual expectations when it is time for you to shop around for your demonstrative evidence solution.

If you’re in luck, you may have good film evidence that clearly shows the fractures in you case. X-rays can be printed and enlarged at a variety of facilities and can often prove to be adequate and inexpensive demonstrative evidence. This works best with long bone fractures in which the fracture is clear and unmistakable. It is not as effective if the fracture is small or in a complex region such as a joint or in the skull since those fractures are more difficult to identify on films. The upsides to simple enlargements include the price that will usually be around $200 and the ease of admissibility. The downsides include lack of drama with static black and white films and the intimidation factor that some laymen may feel when asked to review even the simplest radiological study.

A step above simple film prints is a radiological colorization. This is a process in which your illustrator will create a digital copy of your X-ray, CT or MRI and add simple flat color to the various structures and possibly more detail in the area of the actual injury. While this type of exhibit does not have the detail and clarity of a fully rendered medical illustration, it makes the film more accessible, understandable and dramatic while keeping costs down and retaining the authority of the actual film evidence. Simple colorizations can be acquired in the $300 to $600 range.

Next, in the level of complexity is what I refer to as a radiological film interpretation and is another product option based specifically on the film evidence. Unlike a colorization where simple flat color is added, interpretations provide a fully rendered illustration of the skeletal anatomy based on a precise tracing of the actual film evidence. This type of process gives the image more texture and three-dimensional appearance allowing even the smallest fragments and details to be shown. Since this type of image is more realistic in appearance, it will often be more dramatic as well. The costs for this type of presentation could range from $700 to $900.

Of course anatomical models continue to be a popular option for demonstrative evidence and there is a certain appeal to carrying a physical model into court that one can touch and pass around. The downside is that models most commonly are only available to demonstrate normal anatomy. While it is possible to acquire a custom model showing the actual injury, this custom process is often quite expensive. An alternative is to start with a normal anatomy model or skeleton and have your expert draw on the site or sites of fracture with a marker. While this would certainly help you to identify the sites of the injuries, it does not offer the drama that a depiction of the actual injury would provide. Anatomical models range widely in price, but even a full skeleton can be bought for as little as $300.

The most popular option for medical demonstrative evidence is still traditional medical illustrations. These are images created by a skilled illustrator based specifically on your case information. While these exhibits could certainly incorporate the film evidence, the illustrator is not tied to these films as the only source of information. Therefore, unique views are possible that may not be seen in any one film to best demonstrate the injuries in a clear and dramatic fashion. Surgeries may also be incorporated into medical illustrations. An experienced medical illustrator can interpret the narrative report from a written operative note and provide a step-by-step depiction of the key steps of this procedure. Another popular illustration format is to provide a “progression of condition” showing the same area of anatomy over time. This can allow you to compare normal anatomy, the post-accident injury, the post-operative condition and later complications. Flexibility is the primary attribute for this type of exhibits since almost any conceivable issue can be portrayed. Prices can range from $800 to over $2000 depending on your provider and the complexity of the information.
The most dramatic type of presentation available is custom animation. Today’s technology allows for almost any structure to be modeled electronically in 3D so that your medical animator can show the anatomy, the injury or even the surgical procedure in a fully custom motion picture presentation. These animations present the information in an understandable and accessible way that appeals greatly to the younger generation that has come to expect such media. Animations are especially effective in cases that involve motion allowing you to show how injuries occur, how they affect bodily function or how they are repaired. The downsides are primarily the time and cost involved. Since the animation process is so much more involved, you should anticipate approximately 300 to 400% more time for production with a comparable increase in cost.

The final option we should cover is interactive electronic presentations. The may range from simple PowerPoint presentations combining a few pictures and text pages to fully custom professionally designed programs incorporating animations, video, photographs, illustrations and all kinds of supporting documentation. These types of presentations are growing in popularity as more and more in the legal market become comfortable with the technology required. The primary benefit of electronic presentation is the organizational advantages when all your demonstrative evidence is combined and accessible through your laptop. No longer do you have to carry multiple charts and graphs into the courtroom and constantly put up and take down items from the easel as you move from topic to topic. Disadvantages include the technology and equipment required for display and the possible limitations of your presentation environment. In other words, you will need to have a solution for projecting or displaying the presentation and you will need to become comfortable with the technology required, and you will need to give consideration as to the facility where you will be presenting and determine if any equipment will be available to you and if the light levels will allow for the proper viewing on your projection screen or monitor. Prices vary widely depending on the amount and complexity of your information.

So, as you have seen, even the most simplistic orthopedic case can leave you with a complex set of decisions to make when you begin to plan your presentation. You can stick with the basic traditional approaches or may decide to add dramatic impact by trying more modern technology solutions. Of course price is always and issue, so it is good to determine in advance what your budget will allow. At the end of the day, it all boils down to a question of “how far do you want to take it?”

Failure to Diagnose Coronary Artery Disease

2010-05-06T15:32:00.007-04:00

The large majority of heart attack cases that we see litigated involve a failure to diagnose developing coronary artery disease and, to a lesser extent, the failure to treat it. To help provide a better understanding of these issues I’ll provide an overview of heart attacks and coronary artery disease, the reasons for and risks of misdiagnosis, and the most common types of treatment that are available when a timely diagnosis is made.

Even though blood is pumping constantly through the internal chambers of the heart, separate vessels called coronary arteries run along the surface of the heart and supply the blood to the actual muscles that make up this vital organ. A constant flow of oxygenated blood through these coronary arteries is essential if the heart is to continue working properly. If blood flow through one or more of these vessels is significantly slowed or blocked completely the heart muscle will struggle and eventually die, a condition called myocardial infarction (localized heart muscle death). This blockage of blood flow is most commonly caused by coronary artery disease, although other events such as emboli (blood clots) vegetative growths or even trauma can block these vessels.

Coronary artery disease is a condition in which plaque (plak) builds up inside the coronary arteries. Plaque is made up of fat, cholesterol (ko-LES-ter-ol), calcium, and other substances found in the blood. When plaque builds up in the arteries, the condition is called atherosclerosis (ATH-er-o-skler-O-sis). This is generally a prolonged process that develops over time causing angina (an-JI-nuh) prior to a heart attack. Angina is chest pain or discomfort that occurs when not enough oxygen-rich blood is flowing to an area of heart muscle. Angina may feel like pressure or squeezing in the chest, or may occur in the shoulders, arms, neck, jaw, or back.

Because the formation of coronary artery disease is prolonged and is often heralded by angina pain, litigation often arises when a patient seeks treatment for typical pain complaints but is misdiagnosed when possible links to heart disease are overlooked. Pain is a common complaint and a treating physician may initially suspect that the symptoms are linked to muscle soreness or joint strain in the affected regions including the shoulder and spine. In such cases, specific tests for heart problems may not even be considered much less performed by the physician. This delay may prove disastrous if the blockages of the coronary arteries worsen and lead ultimately to a myocardial infarction.

If detected in time, there are several alternatives for the treatment of coronary artery disease. First, medication may be considered. These medications could include blood thinners to help the blood pass more freely through an area of partial blockage, or clot-buster medications to prevent or break up blood clots that may be contributing to the blockage of blood flow. Blood pressure and cholesterol control medications may also be given to provide more long-term treatment of coronary artery disease.

In addition to medications, there are a variety of surgical options that are also available for the treatment of coronary blockage. These consist mainly of angioplasty and surgical coronary artery bypass. Angioplasty is the treatment of an arterial blockage from the inside of the vessel. A catheter is inserted into an artery in the groin and advanced up through the aorta to gain access to the root of the coronary arteries. Through this catheter an inflatable balloon can be inserted into the area of blockage and expanded to push open a larger channel for the blood to flow. A stent (wire mesh tube) may also be placed into this site to hold the vessel open permanently. Coronary artery bypass involves the placement of a graft from above the site of blockage to below the site to allow blood flow to detour around the blockage. These grafts may be synthetic tubes or vessels harvested from the patients chest or leg. The mammary artery from the chest wall or the greater saphenous vein from the leg are both commonly used for this purpose.

Gastric Bypass and the Roux-en-Y Anastomosis

2010-04-15T16:37:00.005-04:00

There was a time when gallbladder and cholecystectomy issues were the most common medical malpractice cases that we saw. In recent years, complications of gastric bypass surgery may have become even more common in medical malpractice. The rise of the number of these cases being litigated is probably due to a number of factors and is open to debate, so I won't go into that nest of hornets. But I have seen a common need for a general orientation to the anatomy and surgical techniques involved, so that is the topic of this piece.

First, lets cover the purpose of gastric bypass. For those obese patients who find it impossible to lose weight through traditional diet and exercise programs, gastric bypass surgery can be effective. This surgery involves a dramatic reduction in the size of the stomach reducing the amount of food that can be consumed in any one meal and therefore imposing caloric intake restrictions on the patient after surgery.

To understand the surgery, you must first understand the basics of the anatomy involved. Food that is swallowed flows down through a muscular tube called the esophagus that extends from the throat down through the posterior chest, behind the heart, and into the upper abdomen where it empties into the stomach. After being substantially broken down by the gastric juices, the bolus of food then leaves the stomach and moves into the small intestine, another muscular tube that leads to the colon. It is also important to know that bile from the liver and pancreatic juices from the pancreas, which both affect digestion, also empty into the first segment of the small intestine just past the stomach.

In a gastric bypass the stomach is divided so that only a small portion of the upper part of the stomach is left attached to the esophagus. Although food can still get into this small pouch through the esophagus, it cannot get out, so a way must be devised to allow the food to exit. To accomplish this, the small intestine is divided a few feet below the stomach and the distal (furthest away) segment is pulled up and attached to the bottom of the stomach pouch. This connection of the small intestine to the newly created stomach pouch reestablishes the flow through the digestive system, but what of the gastric juices in the lower part of the stomach and the bile and pancreatic juices that enter into the proximal small intestine? They still need a route to escape and join with the digestive contents. Therefore the small segment of the small intestine above the loop that has been pulled up to the stomach is attached to the side of this loop so that the digestive juices in the proximal segment can join with the flow well below the stomach. When you look at this new architecture of the small bowel, it appears to form a Y, thus the name "Roux-en-Y".

Finally, let's look at the language a bit more closely. Most laymen are put off by the excessively medical sounding title "Roux-en-Y anastomosis". Don't let the name scare you. First, what is an anastomosis? It's simple. Just know that an anastomosis is a connection between two tubular structures. This could be a connection between two blood vessels, two bile ducts or in this case, two segments of bowel. So what about Roux-en-Y? Don't let the name of the famous Swiss surgeon throw you off. A Roux-en-Y anastomosis is any connection of any two segments of bowel in a Y-shaped pattern, so the "Y" part of the name is what is important for you to remember. So long as you understand that this procedure involves a transection of the bowel, connection of the distal segment to the stomach and connection of the proximal segment of the bowel lower down on the distal segment, it will be clear to you. See the animation at the top of the article and you will see that this is a rather straightforward concept.

Understanding Spinal Surgery

2010-03-22T15:31:00.004-04:00

Although previous articles have covered the basics of intervertebral disc injuries, as well as some other more unusual spinal injuries, I have been told that I have neglected to give a good overview of the more common spinal surgeries. Certainly it would be impossible to cover all the possible surgical procedures one might encounter in a case involving a spinal injury, but I can certainly provide a brief orientation to the surgeries most commonly seen in this type of litigation. These procedures include cervical, thoracic and lumbar surgeries, both anterior and posterior exposures, and everything from laminectomies and discectomies to foraminotomies and fusions.

Of course, as with any surgery, to fully understand what is being done you need a good fundamental grasp of the anatomy. But often I see that understanding each and every structure in the spine or struggling with the long words used in these surgeries is an impediment to a basic understanding of the procedures. I find that, rather than dwelling on
the discs and various intricacies of the vertebrae, it is easier to first understand the simple basics of the spinal cord and nerve roots since the vast majority of these surgeries boils down to stabilizing or relieving pressure on these nerves. Think of the spinal cord as a major highway that runs its entire course within a tunnel. This tunnel is the spinal canal formed by the rings within the various vertebrae that are stacked one below the other from the skull all the way down to the pelvis. Think of the nerve roots as exits from the spinal cord highway that need to emerge from the tunnel of the spinal canal. These nerve roots exit through foramen, or channels, on either side both right and left where every two vertebrae come together. The surgeon’s primary concern is maintaining the flow of traffic through this highway and on these exits, making sure that the spinal cord and nerve roots are not compressed or pinched.

Let’s talk about the four most common types of spinal surgery first. These are laminectomy, discectomy, foraminotomy and fusion. We’ll deal with each separately although there is some crossover and any combination of these might be performed in the same surgery.

• Laminectomy – While the vertebral bodies and discs lie anterior to the spinal cord, the laminae are the flat shields of bone that form the posterior (back) border of the spinal canal. They normally protect the spinal cord from being damaged from direct impact from behind. If the disc protrudes beyond its normal location back into the spinal canal, the spinal cord can become compressed between the protruding disc material and the laminae. A laminectomy, or removal of the laminae, can be performed to decompress the spinal canal and give the spinal cord a bit more room to move around. This may be all that is required to relieve the problem. More often, the laminectomy is performed not so much for decompression, but rather to allow the surgeon to access the deeper structures within the spinal canal, to create a doorway. Variations of the laminectomy are the hemilaminectomy when only the right or left half of the laminae are removed, and the laminotomy in which only a window of bone is removed from the lamina.

• Discectomy – This procedure is simply the removal of all or part of the damaged intervertebral disc either because it is bulging or herniated back into the spinal canal. This can be done from the front (anteriorly) or from behind (posteriorly). The anterior approach is generally preferred in the cervical spine (neck) since it allows the surgeon to access the disc without having to manipulate or go around the spinal cord and therefore avoiding damage to the cord. On the other hand, even though the spinal cord has to be manipulated, a posterior approach is traditional in lumbar (lower back) cases since this approach avoids the issues of the abdominal structures and major vessels that lie anteriorly. But, over the years, anterior approaches in lumbar cases have become more and more common. Today you may be just as likely to encounter an anterior lumbar procedure.

• Foraminotomy – This procedure is simply an enlargement of the neural foramen, the channel through which the nerve roots exit the spinal canal. This passageway may be narrowed due to herniated disc material or by degenerative arthritis that manifests as an overgrowth of bone. Regardless, for one reason or another, if the foramen becomes narrowed it can put pressure on the exiting nerve root. This can lead to severe pain and neurological dysfunction. To relieve this condition the surgeon must access the foramen and scrape it out removing the offending disc or bone material.

• Fusion – Certainly there are more types of spinal fusion techniques than I can count on my fingers and toes combined. It seems that every year there are new hardware and materials being developed and new techniques associated with each. But let’s stick with the basics. If a disc is damaged and must be removed or if the interspace between two or more vertebrae is unstable, a fusion can be performed to make a permanent connection between two or more vertebrae. The eventual goal of any fusion procedure is to actually get the bone of the fused levels to grow together, using the power of the body’s own healing ability to create a strong connection. But this takes time, so a variety of hardware can be employed to temporarily stabilize the fusion site while the bone growth takes place. This hardware may consist of devices placed within the disc space, or plates, screws and rods placed either anteriorly or posteriorly. Due to the variety possible, I will publish future articles dealing with this topic in more detail.

Finally, I will mention a few additional procedures that, although not as common as those described above, may be encountered from time to time in your practice. A corpectomy is the complete or partial removal of a vertebral body. A kyphoplasty is the injection of cement or other synthetic material into a compressed or collapsed vertebral body to restore the proper height and alignment. Intradiscal electrothermal (IDET) therapy is the insertion of a wire or coil into a damaged disc that can be heated to cause the disc material to contract and relieve nerve compression. A disc replacement is the placement of a mechanical device into the disc space to restore stability without the loss of flexibility caused by traditional fusion. Click on any of the links above to see examples of the various procedures discussed in this article.

Shoulder Dystocia: Beyond The Basics

2010-02-15T15:22:00.004-05:00

Most of you will have already read my January, 2009 article on the basics of shoulder dystocia and are familiar with the most common type of dystocia, or impediment to the delivery of a baby, where the anterior shoulder of the baby becomes lodged behind the pubic symphysis at the front of the mother’s pelvis. This is called anterior shoulder dystocia and accounts for the vast majority of dystocia cases I see litigated by my clients. If you are familiar with anterior shoulder dystocia, you have a great foundation, but there are other types of dystocia and other topics associated with this issue that I will cover in this article. This will provide you with a more advanced understanding of what you may encounter in future obstetrics malpractice cases.

Unlike anterior dystocia, where the anterior shoulder of the baby becomes lodged, in posterior shoulder dystocia the shoulder of the baby that is closest to the mother’s spine or sacrum is the one that becomes stuck. Generally, this posterior dystocia occurs when the posterior shoulder of the fetus becomes lodged on the protruding sacral promontory, which is the upper lip of the sacrum at the base of the lumbar spine. Also, I have seen one case that involved a mother with an unusually curved coccyx, tailbone, on which the posterior became stuck. Either way, the point is that posterior shoulder dystocia, while rare, is possible, so you should be sure of the facts before you assume your case involves the more common anterior type.

Another issue that arises in many of these shoulder dystocia cases is the actions taken by the healthcare provider that might exacerbate the situation. While attempting to dislodge an infant that is not progressing there are many things that should not be done, but in my experience there are two mistakes most commonly associated with brachial plexus nerve injuries. The first is excessive traction or pulling on the baby’s head, especially traction in which the head is pulled downward away from the lodged shoulder. This traction can be done with the hands, with a vacuum extractor or with forceps, and while some traction is necessary in many births, excessive traction in cases of shoulder dystocia can lead to devastating nerve injury. The second issue is fundal pressure. This is when a nurse or assistant pushes down on the upper part of the mother’s abdomen in an attempt to force the baby out. Once again, in cases where the shoulder is stuck, this force can lead to nerve injury. Force is the issue whether it is pulling force or pushing force. If the shoulder is stuck, it must first be dislodged before labor can progress.

Although downward traction and fundal pressure are maneuvers that should be avoided, there are several acceptable maneuvers that can often release the shoulder of the infant. Of all of these, some so desperate that they include fracturing the collar bone of the fetus, there are three that we so most frequently in these cases. The first is called the McRoberts maneuver. This is simply the elevation of the mother’s legs with the knees forced back toward the abdomen. This flexion of the hips causes a substantial change in the angle of the pelvic outlet that can often allow for more easy passage of the infant. Next, there is suprapubic pressure. In this maneuver, a nurse or assistant presses down on the lower abdomen directly above the mother’s pubic bone providing direct pressure on the baby’s shoulder and hopefully dislodging the dystocia. Finally, there is the Woods corkscrew maneuver. This maneuver involves the insertion of the doctor’s fingers into the vaginal canal just behind the baby’s posterior shoulder. Then, with gentle pressure, the shoulder can be rotated in a corkscrew fashion turning the baby into a more horizontal orientation and releasing the anterior shoulder from behind the pubic symphysis of the mother.

Mechanism of Pulmonary Embolism

2010-01-12T15:56:00.002-05:00

Looking back on 2009, our records show that, once again, pulmonary embolism ranked as the most common medical malpractice issue litigated by our clients. These cases involve blood clots formed in the veins that break off and travel to the chest, through the heart to become lodged in the lungs causing respiratory distress. The popularity of this topic encourages me to provide my readers with a bit of background information. Although the basic mechanism of a pulmonary embolism is straightforward, there are associated issues and terminology that you should be familiar with before you encounter one of these common cases in your future practice.

First of all, why are pulmonary embolism cases so common? Most likely this is because pulmonary emboli can be secondary conditions resulting from prolonged inactivity such as surgical procedures, bed rest or even lengthy airline travel. Therefore, there are a large number of situations that might put a person at risk for this dangerous complication. Generally litigation revolves around the failure to prevent, diagnose or properly treat these emboli.

To understand the mechanism of a pulmonary embolism, we must first understand the anatomy of the veins. The veins are the system of vessels throughout the body that return blood from the various body regions to the heart. Unlike arteries, the veins do not have high internal pressure to keep the blood moving along but actually require assistance from the muscle contractions involved in normal daily activity. This problem of moving the blood along is most pronounced the further the veins are from the heart, and since gravity also acts against venous flow the flow of blood is slowest in the lower extremities (legs and feet). This slowing of blood flow in the veins is a key component in the mechanism of pulmonary embolism. In situations when the body is immobilized due to surgery, convalescence or prolonged inactivity there are no muscle contractions to assist in speeding blood flow. In these cases, flow can slow to such an extent that the normal clotting factors within the blood begin to react and form blood clots. This is often seen at the site of a valve in the vein where blood can pool within the eddy behind the leaflet of the valve. This clot that remains at the site in which it originally formed is referred to as a thrombus. The formation of these clots is called deep vein thrombosis (DVT).

Once a thrombus is formed within a deep vein, it will continue to grow as additional clotting factors collect and adhere themselves to the original clot. But this thrombus is not completely stable. The real problem lies in the fact that pieces can break off from the thrombus and join in the blood stream to be carried upward toward the heart and lungs. Once a clot joins the blood stream and begins to move, we no longer call it a thrombus. It is now called an embolus. To reach the heart and lung from the legs, the embolus must travel up through the inferior vena cava, a large vein in the posterior abdomen. Eventually the embolus will reach the heart where it will travel through the left atrium and ventricle and be pumped out into the pulmonary arteries that lead to the lungs. This embolus will continue to travel within the pulmonary vasculature, which divides again and again into smaller and smaller arteries within this tree-like network, until the embolus reaches a vessel too small to pass through. At this point the embolus will become lodged forming a dam that will block further blood flow through this artery. This blockage of blood flow and the resulting reduction in lung function is called an embolism.

Generally, the smaller the embolus, the less severe the effects will be since a smaller percentage of lung volume will be affected by the blockage of a smaller pulmonary vessel. But often there are a number of emboli released at once or over time leading to a "shower" of emboli that can cause multiple blockages to one or both lungs. These multiple blockages can be as severe as one larger blockage resulting in a higher percentage of total lung function being lost. The most severe form of embolism is referred to as a saddle embolus. This type of embolus is so large that it cannot pass beyond the bifurcation (division) of the main pulmonary trunk into the left and right main pulmonary arteries and therefore causes a sudden blockage of blood flow into both lungs. This condition can often be almost instantly fatal.

The healthcare provider's first responsibility is prevention of deep vein thrombosis. During prolonged surgery, compression stockings and pneumatic compression devices can be used to increase circulation and prevent the pooling that leads to thrombosis. Medications can also be given to thin the blood and prevent clotting. If prevention of clotting in the legs is unsuccessful, medication or even surgery may be necessary to break up and remove the clots from the deep veins. Also, mechanical filters can be placed within the inferior vena cava beneath the heart to prevent emboli from reaching the lungs.

So, as you can see, these cases are generally rather straightforward. A thrombus forms in the deep veins due to inactivity. Pieces of the thrombus break of and join the bloodstream as emboli. These emboli travel through the inferior vena cava and heart to the lungs. These emboli block blood flow through pulmonary arteries creating an embolism that can lead to respiratory distress and possibly death. Those are the basics, and if you can appreciate the basic mechanism, it should be easy to understand any slight variations that may arise in any unique case.

Presenting Multiple Injury Cases

2009-12-10T15:33:00.011-05:00

A good client called this week to discuss her latest case involving a car v. pedestrian collision. It was a great case with no real issues concerning liability, but the presentation of the medical facts was going to be a challenge since the case involved over a dozen traumatic injuries and over fifty surgical procedures. While consulting in this case, I realized that I had offered the same suggestions many times before in similar cases which inspired me to write up a general overview to assist all of you. When considering presentation options for cases involving multiple injuries, there are two specific areas you need to consider: effectiveness and budget. Due to the massive amount of information that may need to be portrayed, these two factors are often in conflict and need to be balanced.

When I say that you need to consider the effectiveness of your presentation, I am referring to the strategic organization of the information, the educational value of the visuals you select and the dramatic impact of those visuals. If these three factors come together well, you will have a better chance of creating an effective presentation that will help you to achieve your goals. In cases with an overwhelming amount of information, the biggest challenge is usually the strategic organization. You can't show everything at once, so which items should be grouped together and in what sequence should they be displayed?

In general the information can be arranged chronologically, anatomically or strategically. A chronological organization could show all the injuries at one time, all the initial surgeries next and all the secondary surgeries later. An anatomic presentation would organize the information by body region. For example, you might show the head injuries first, the spine injuries next and then show the ankle injuries last. These exhibits might combine post-accident, intra-operative and post-operative information together so that each body region could be covered fully before moving on. A strategic presentation revolves more around the testimony to be given. In a strategic presentation, you might choose to divide the information according to how you will get it admitted or by which information each expert will discuss. Therefore, you will concentrate your efforts on illustrating items of interest to the experts who will appear live at trial or will be deposed on video while leaving off issues which are not supported by the experts you have at your disposal.

Next we must consider the education value of our presentation. If we can't afford to create demonstrative evidence for all the issues, we should at least use the power of illustrations for those that are the most complex or difficult to understand. For example, you might instinctively hope to illustrate the dramatic open fracture of the lower leg including the surgical fixation with multiple plates and screws, but there's also a pulmonary embolism to consider. Although the leg fracture and fixation would be impressive as an illustration, it would probably be easy for a lay audience to understand the issues without demonstrative evidence. On the other hand the formation and consequences of the pulmonary embolism would be exceedingly difficult to describe verbally and would most likely be a better focus for a limited budget. The object is to concentrate your efforts in areas where you need the most assistance in making yourself understood.

Last but not least, in order to insure your presentation is effective, you need to consider the dramatic impact of your demonstrative evidence. Drama can be important for many reasons from holding the attention of your audience and making your presentation memorable, to increasing sympathy for your client and increasing the amount of your award. For many, dramatic impact is the most important factor when gauging effectiveness, outweighing the other issues of educational value and strategic organization. Basically, in any multiple injury case, some issues, injuries and surgeries are just going to be more dramatic than others. No matter how important this aspect of effectiveness is to you personally, it is certainly something that needs to be considered when making the decision as to how to allocate resources.

And that leads us to the consideration of your budget. Thankfully, we have already covered almost all the aspects of this consideration while discussing the issues involved in the effectiveness of your presentation. All considerations must be weighed against the others when the information available is too voluminous to be covered comprehensively. Your budget will only set a guidepost for how severely you must sacrifice some considerations when weighting your presentation toward another. For example, if your budget only allows for one topic to be covered by your demonstrative evidence, you may need to select the exhibit that would be the most educational, or that would be the most dramatic or that would specifically support the testimony of the one expert who will be testifying live, but you may not be able to full achieve all three. With a larger budget, you will need to cut fewer corners but decisions will still need to be made.

My opinion is that the best decision is an informed and purposeful decision. You may have made these decisions many times although you may not have been consciously aware of the options you were considering. Hopefully, now that we have discussed the various considerations in detail, you can more purposefully weigh the various options you have and make decisions with which you can fell confident. Of course, I'm always available to discuss options with you, if you feel you need additional assistance.

Advanced Spinal Injury Concepts

2009-11-06T10:51:00.000-05:00

Frequent readers of my blogs and articles will have read entries concerning disc bulges and herniations and also covering discogenic pain. Those topics concerning the intervertebral discs, along with various traumatic fractures of the spine, make up the vast majority of the spinal injuries involved in litigation. For that reason, most trial attorneys have at least a passing familiarity with these concepts. But there are other issues involving the spine that may be encountered from time to time. These include spondylolisthesis, spondylolysis, spondylosis and ankylosis, and involve different areas of anatomy including the pars interarticularis and the facets. Since these terms are more unusual, fewer attorneys are familiar with these concepts, so today I will provide you with a general overview so that you may be more comfortable when encountering these conditions in future cases.

First, let us begin by discussing the anatomy of the spine. The spine is made up of multiple individual bones called vertebrae that provide support for the weight of the upper body and provide protection for the spinal cord by surrounding it with an armor of bone from the skull all the way down to the pelvis. Each vertebra can be described as a ring with the large cylindrical vertebral body forming the anterior aspect of the ring and the laminae and spinous processes forming the posterior aspect of the ring. The vertebral bodies are aligned with one atop another forming a column providing the majority of the support for the spine. The laminae form a shield protecting the posterior aspect of the spinal cord. It is important to note that the region of the vertebrae where the posterior aspects join with the anterior aspects is called the pars interarticularis. Also there are joints where the posterior elements of each vertebra come together above and below, and these are called facets. Finally, we must understand that the spinal cord branches into nerve roots at each intervertebral level and that these nerve branches exit the spine through channels called foramen that run beneath the facets.

Now that we've covered the pertinent anatomy, let’s discuss the various pathologies that you might encounter when researching a spinal injury. Of course, as mentioned earlier, disc herniations and spinal fractures are the most common injuries you will come across, but there are other conditions you will see from time to time. Spondylolisthesis, sometimes referred to as anterolisthesis, is a defect in the alignment of the vertebral bodies allowing one vertebral body to slip forward over the vertebral body at the level beneath. In most cases the entire spine, above the level of the defect, is displaced anteriorly. In other words, if you have a spondylolisthesis at L5-S1, the L5 vertebral body will be displaced forward in relation to the sacrum (S1) but L5 will still maintain its proper alignment with L4 and the other vertebrae above. While it may be easy to imagine this change in relationship between the vertebral bodies, it is more difficult to visualize the changes in the posterior aspect of the spine that allow this displacement to occur. In order for the vertebra to move forward the posterior articulations at the facets must be either dislocated or weakened, or there must be a separation in the pars interarticularis (another condition called spondylolysis) allowing for a separation of the vertebra itself. While such a defect in the pars is generally a congenital or pre-existing condition, trauma can cause a worsening of the actual displacement resulting in the spondylolisthesis that is eventually diagnosed. Spondylolishesis is a problem because it can change the passageway for the spinal cord down through the spinal canal causing compression or stretching of the spinal nerves. It can also place tension of the exiting nerve roots at the specific level of displacement or may be associated with a disc herniation at the level of instability. Spondylolisthesis can be mild to severe and if symptomatic is generally treated with a spinal fusion procedure including bone grafts and fusion hardware.

The final pathology we will discuss is spondylosis (sometimes referred to as ankylosis). Basically, this is simply arthritis of the spine. This arthritis may develop over time following the trauma involved in a case, or it may be preexisting and exacerbated by the injury of your case. As with all forms of arthritis, spondylosis primarily affects the joint surfaces. This can include the endplates of the vertebral bodies adjacent to the discs in the anterior aspect of the spine, or the articular surfaces of the facet joints in the posterior aspect of the spine. As with other forms of arthritis, this condition can cause localized pain within the joints themselves or can cause overgrowths of bone (bone spurs or osteophytes) that can protrude into vital regions causing compressions of vulnerable nerves including the spinal cord and nerve roots. As we learned earlier, the foramen through which the nerve roots travel are adjacent to the facets, so overgrowth of arthritis in this area can narrow these foramen and impinge upon the nerve roots. Spondylosis can be treated with a variety of procedures ranging from simple steroid injections to widespread spinal fusion surgery, based on the severity of the condition. The key issue is to remember that although this is an arthritic condition, it can be still linked specifically to trauma.

Classification of Burns

2009-10-05T13:11:00.009-04:00

How do you classify burn injuries? At one time, this was a fairly simple question to answer, but the classification of burns is changing and a new system is gradually being adopted. This has made conversations about burns more complicated since you need to be sure that everyone concerned is using the same system and terms. This article will cover the basics and discuss terminology that you might face when handling your next burn injury case.

Traditionally, burns have been categorized as first-, second-, or
third-degree. This system is defined by the following categories:

• First-degree burns affect only the epidermis, or outer layer of
skin. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example.

• Second-degree burns involve the epidermis and part of the dermis layer of skin. The burn site appears red, blistered, and may be swollen and painful.

• Third-degree burns may also damage the underlying bones, muscles, and tendons. The burn site appears white or charred. There is no sensation in the area since the nerve endings are destroyed.

For many years, healthcare providers have also added a fourth-degree category. Using this system, third-degree burns are limited to those that extend down through the epidermis and dermis into the subcutaneous tissue, and fourth-degree describes the burns that extend down into the underlying muscles, tendons and ligaments.

Recently, a new system has come into use. This new system completely abandons the old use of degrees and describes the injuries based specifically by the depth of the burn. The traditional classification of burns is being replaced by the designations of superficial, superficial partial thickness, deep partial thickness and full thickness. Of course, these designations refer to the depth of the skin affected by the burn.

For now, the change in systems is still in progress, so during the transition you will notice a blend of terminology. Some experts may refer to first-degree, second-degree, third-degree and full thickness burns. Some may use a combination of terms such as first-degree/superficial, second-degree/partial thickness, third-degree/deep partial thickness and fourth-degree/full thickness. The variations can become confusing, so it is good to be versed in all the terms and systems discussed above.

Variations in Fetal Orientation During Pregnancy

2009-08-31T14:53:00.013-04:00

Obstetrics litigation often boils down to a question of what events occurred within the uterus during development or during the birthing process. Often, if we are to understand what happened to the fetus at a crucial moment in the pregnancy, we need to have a clear understanding of how that fetus is positioned within the uterus or the birth canal. For this reason, issues of fetal lie, presentation, position or station are eventually discussed in almost all obstetrics cases. Therefore, I will try to provide you with a basic understanding of these concepts so that you can better visualize the wide variety of ways that the baby can be positioned within the mother.

First of all we have to establish our terms. For the purposes of this conversation, I’d like for you to visualize the mother in a standing position so that “down” is toward her feet and “up” is toward her head. “Posterior” is toward her back and “anterior” is toward her front. Right will always mean her right regardless of how the baby is positioned or how you are standing. Just remember that when I use directional terms, it’s all about the mother.

Keep in mind that it is of paramount importance to know the orientation of the fetus within the uterus, particularly at the onset of labor. Orientations that are not ideal may require intervention and, in some situations, cesarean delivery may be the only viable option. During labor, an appreciation of the fetal station within the birth canal can help us to judge how the labor is progressing and which delivery techniques may be warranted at a given time.

Traditionally, the orientation of the fetus is described with respect to its lie, presentation and position. I will provide an overview of these terms. The lie of the fetus can be either longitudinal or transverse. In other words, the long axis of the fetus can either be parallel or perpendicular to the long axis of the mother. Luckily, the fetal lie is longitudinal in about 99% of cases. This is a good thing since a transverse lie cannot allow for the proper vaginal delivery of the fetus.

Once we know the lie, we can determine the presentation. The presentation can be either cephalic or breech, which means that the fetus can be either “head-down” or not. There are a number of different types of cephalic presentation, but the most common is called vertex presentation which refers to the fetus entering the birth canal head first with the upper occipital (back) portion of the head leading the way.

Next, the position of the fetus can be established. Position refers to the relation of the occiput (back of the skull) of the fetus to the left, right, front and back of the mother. In other words, if we know that the back of the fetal head is facing the front of the mother, this is called the occiput anterior (OA) position and if the occiput is facing the right side of the mother, this is called the right occiput transverse (ROT) position. Any combination of these, where the occiput of the fetus is toward the right and toward the front in a diagonal fashion, is called the right occiput anterior (ROA) position. This convention allows us to note any one of the following eight positions: occiput anterior (OA), right occiput anterior (ROA), right occiput transverse (ROT), occiput posterior (OP), left occiput posterior (LOP), left occiput transverse (LOT), and left occiput anterior (LOA).

Finally, we can discuss fetal station. The fetal station is a measurement of how far the fetus has progressed down through the birth canal during delivery. This measurement reflects the relationship of the leading edge of the fetus, generally the top of the head, to the ischial spines of the mother’s pelvis that are halfway between the pelvic inlet and pelvic outlet. When the leading edge of the fetus reaches the ischial spines, this is called zero (0) station. In the currently used “fifths” system the space is divided above and below 0 station in one centimeter increments, so that the space above the ischial spines is designated from -5 station to 0 station and the space below the ischial spines is designated from 0 station down to +5 station. With each centimeter that the leading edge of the fetus progresses, you reach a new station of presentation (-5, -4, -3, -2, -1, 0, +1, +2, +3, +4, +5).

You should be aware that a previously widespread system, the “thirds” system, divided the space above and below the ischial spines into arbitrary thirds so that the stations progressed from -3 to +3 without regard to actual centimeter measurements. This is important because only 0 station coincides in these two systems and you can get an inaccurate picture of the case facts if the correct system is not used. To complicate matters, many doctors and hospitals still refer to the old system so it is best to establish early which system is being used in the records of any particular case.

These are the key terms that you will encounter when researching almost any case involving birth injuries or obstetrics mal practice. Hopefully this overview has given you a better understanding of the varieties of fetal orientation and will help you to better visualize the lie, presentation and position of the fetus within the womb.

Nursing Home Negligence Cases

2009-08-11T14:18:00.010-04:00

One of the most common nursing negligence issues we are called upon to illustrate is the development or progression of pressure sores (sometimes know as bed sores or decubitus ulcers). Pressure sores are areas of injured skin and tissue usually caused by sitting or lying in one position for too long. This often happens if you use a wheelchair or you are bedridden, even for a short period of time (for example, after surgery or an injury). When a change in position doesn't occur often enough and the blood supply gets too low, a sore may form. The constant pressure against the skin reduces the blood supply to that area, and the affected tissue dies.

A pressure sore starts as reddened skin but gets progressively worse, forming a blister, then an open sore, and finally a crater. The most common places for pressure sores are over bony prominences (bones close to the skin) like the elbow, heels, hips, ankles, shoulders, back, and the back of the head. Pressure sores are categorized by severity, from Stage I (earliest signs) to Stage IV (worst):

• Stage I: A reddened area on the skin that, when pressed, is "non-blanchable" (does not turn white). This indicates that a pressure ulcer is starting to develop.
• Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated.
• Stage III: The skin breakdown now looks like a crater where there is damage to the tissue below the skin.
• Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes tendons and joints.

In most cases pressure sores are preventable and, if not prevented, should be recognized early and appropriately treated. In almost all situations, the development of massive pressure sores is evidence of some form of deviation in the standard of nursing care (neglect). Generally the neglect is in more than one area, i.e., hygiene, nutrition, infection control, protection and positioning.

The common areas for the formation of pressure sores and their prevention is a basic area covered in all nursing schools by all licensed nursing programs (LVN or RN). Prevention consists of changing the person's position every two hours or more often if needed. The two-hour time frame is a generally accepted maximum interval that tissue can tolerate pressure without damage. Prevention also consists of protection and padding to prevent tissue abrasion as well as the elements of nutrition, hydration, hygiene, etc. Turning and positioning is common knowledge for physicians, licensed nurses (LVN or RN), and physical therapists as well as paraprofessional care gives (nursing assistants). Turning is applicable even on flotation mattress beds.

Treatment for pressure sores involves removing all pressure from the involved area(s) to prevent further decay of tissue and promote healing. Frequent turning is mandatory to alleviate pressure on the wound and to promote healing. Treatment also involves keeping the area clean, promoting tissue regeneration and removing necrotic (dead) tissue, which can form a breeding ground for infection. There are many procedures and products available for wound care, cleaning and pressure reduction. The use of antibiotics when appropriate is also part of the treatment. Some deep wounds even require surgical removal or debridement of dead tissue. Without all of these elements being in place, the wounds will not heal and, in fact, will quickly worsen.

Linking the Evidence of Traumatic Brain Injury

2009-07-17T14:01:00.010-04:00

Brain injuries are one of the most common topics involved in personal injury litigation. Motor vehicle collisions, falls, sports injuries and many other circumstances with associated impacts frequently damage the brain, the most important and vulnerable organ in the body. The severity of these injuries can range from mild to severe. Cases may or may not involve surgery or other medical interventions. But in almost all brain injury cases, there exist similar challenges for selecting or crafting demonstrative evidence.

In traumatic brain injury cases, you will most likely have significant radiological evidence. Hematomas, contusions, and areas of infarction, etc. typically show up nicely on CT or MRI studies. You may choose to simply utilize these radiological studies as your demonstrative evidence. While this is certainly the most affordable option, you should consider having a skilled medical illustrator either highlight these films, coloring the pertinent regions, or have the illustrator create full color illustrations interpreting the films in greater detail. These are generally some of the most affordable custom exhibits you could purchase, but they certainly make a big difference in clarifying the injuries for the layperson.

Your next most valuable bit of evidence may be the neurological evaluation. This report will detail the neurological deficits or behavioral changes experienced by the patient following the injury. This report in itself is a valuable tool, but it can be even more effective if you can create a direct link between the radiological evidence and the neurological evaluation. For example, if your neurological evaluation discusses significant changes in the patient's short-term memory and balance and we can clearly see a physical injury on the radiological studies that affects the temporal lobe, then we have an opportunity for the foundation of a great argument linking these factors. Since the temporal lobe is damaged and the temporal lobe is responsible for the symptoms experienced by the patient we must create a visual link for the jury so that there is no doubt that the two reports are related. It doesn't matter if you employ a simple chart mapping brain functions or a complex presentation concentrating on your specific area of interest. The goal is to establish a foundation of knowledge in the viewer so that the links between cause and effect can be appreciated.

For any neurological evaluation, you should take the extra time to inquire from the neurologist, not only what deficits can be seen, but also what regions of the brain influence the pertinent brain functions. After the region of functional deficit is determined, you can go back to the original diagnostic radiological studies to see if the visible injury is in the same region. The brain is complex, so you may not always have a direct match, but in those cases where the two reports coincide, you would be well served to take the time to educate your audience on the functional regions of the brain. This way a direct link can be drawn between the injury and the subsequent neurological symptoms.

Of course, there are many other types of demonstrative evidence that can be useful in these traumatic brain cases including dramatic illustrations of brain surgery or mechanism of injury animations. Perhaps that will be a topic for another day.