Infection from Intravenous Fluids - Malpractice Case

Infection from intravenous fluids are given through a needle or catheter (plastic tube). These are inserted in the vein by direct puncture through the skin, but the skin must be cleansed beforehand and the locations of the needles and catheters should be changes every twenty-four hours.

When allowed to remain in place for a longer period of time, the risk of infection substantially rises. There is a significant incident of death from overwhelming infection (sepsis) caused by the persistent use of catheters, which become contaminated.

The catheter site will be a source for external germs to invade the body directly into the blood stream.

Germs also grow in the small clots that develop around the catheters and are continually shed into the blood stream. In the presence of new and unexplained infection, all intravenous catheters must be removed and their tips cultured for germs. The failure to remove them is negligence.

This medical malpractice article was written by an expert witness working with American Medical Experts, LLC (AME). AME is the nation’s leading source of medical experts for case review and testimony; AME also offers the lowest flat rate fees on Complete Case Reviews ($695) and Expert Witness Reports ($995). For more information, call 888-678-EXPERTS (888-678-3973) or visit AmericanMedicalExperts.com.

Operations looking for Indications in Cardiovascular Medicine

A shift has occurred in American medical practice, often the primary focus of the "medical machine" is to make a profit and therefore much of the current treatment and therapy in cardiovascular medicine is not always in our best interest.

There is no evidence that the use of cholesterol lowering drugs extends our lives, in fact the overall death rate from the use of "cholesterol lowering drugs" has increased the overall mortality in cardiovascular patients. Along those same lines there is no evidence that coronary bypass surgery or angioplasty with or without stenting extends the life of the cardiovascular patient, it may abort an acute event, but survival tracts the usual course of the disease.

The current therapy of the cardiovascular patient is to use statins to lower cholesterol, decrease the heart rate, if symptoms present (angina) perform an angiogram. Angioplasty or stent any lesion "they deem the culprit lesion" Add an antiplatelet drug, if angina returns, repeat angiogram, repeat angioplasty or stent, repeat scenario if necessary. Refer for surgery when unable to stent any more arteries.

Hence the problem, who is watching the cardiologists and cardiovascular surgeons if money is to be made doing procedures, and in some cases unnecessary, repetitive procedures but reimbursed by insurance companies and Medicare. As a cardiovascular surgeon and often called to the catheterization laboratory by cardiologists to review an angiogram for "an opinion" I am often bewildered that the patient has been catheterized multiple times, angioplastied multiple times and has several stents in multiple coronary arteries. What do you think? is the question most often posed to me by the cardiologist, well "I think this patient should have had bypass surgery 5 years ago after the third angioplasty" is my reply, but "how can help the patient" is what comes out of my mouth.

If we are to instill patient confidence and treat the disease at the standard of care, we must be collaborative, not "protecting our vested, like 401K, interest in the patient". In other words, get a second opinion early in the course of the disease, do not return the patient to the catheterization laboratory multiple times looking for an operation (stent or angioplasty) with minimal indications and when three vessel disease is present refer for a surgical opinion. It may be possible to operate at that point with a minimal morbidity or mortality, but often times it is not. Hence the increase in cardiac catheterization procedures and the decrease in cardiovascular surgical procedures, and shamefully, sometimes inappropriately.

A word in closing, when reviewing cases for appropriateness of care, standard of care, in cardiovascular medicine cases I often look for indications for the procedure based on symptoms, appropriateness of the procedure and most importantly collaboration between the cardiologist and cardiovascular surgeon. If I see that a cardiologist has had his "vice-grip" on a patient for several years performing what we call "outlier" procedures, the red flag is raised. If your client has had multiple procedures and without the benefit of a second opinion by a cardiologist or cardiac surgeon and incurred a major avoidable complication I would be suspect that the guidelines for the treatment of cardiovascular disease were not met.

About the Expert:

This expert is a board certified cardiovascular and thoracic surgeon with over 27 years of practice experience. He is a member of the American College of Surgeons, national, international surgical societies and a peer reviewer for two state medical boards.

This medical malpractice article was written by an expert witness working with American Medical Experts, LLC (AME). AME is the nation’s leading source of medical experts for case review and testimony; AME also offers the lowest flat rate fees on Complete Case Reviews ($695) and Expert Witness Reports ($995). For more information, call 888-678-EXPERTS (888-678-3973) or visit AmericanMedicalExperts.com.

Dialysis Unit Communication - Real Time or Real Problem

Dialysis Unit Communication: At present there are more than 6500 dialysis centers in the United States that provide life saving care for patients with End Stage Renal Disease (ESRD) requiring renal replacement therapy. This often thrice-weekly form of treatment has become commonplace in virtually every major city and suburb in the US. Dialysis care is almost universally provided by Nephrologists (physicians specializing in the diagnosis and treatment of kidney diseases) in close collaboration with a team of health care providers that includes specially trained dialysis nurses technicians, social workers and dieticians. Dialysis care is now considered sufficiently routine that the Nephrologists need not to be present during each treatment.

Potential Consequences of Dialysis:

As with any procedure, hemodialysis carrels a small but significant risk of complication including infection, low blood pressure, and bleeding. The risk of chronic blood loss is real, even under ideal conditions; however, blood loss may also be acute, especially in patients with plastic dialysis catheters that are susceptible to accidental disconnection during or after the dialysis procedure.

Standard of Care: Recent evidence suggests that hemodialysis units widely vary in standardizing communication when untoward vents occur in the absence of the Nephrologist. While some units report any unit ward event, others elect not to inform the Nephrologist, potentially causing these events to be unaddressed, thereby increasing the risk of recurrence, complications and even death. Partly as a result to this variability in practice, it is necessary for physician to review the “event threshold” that mandates communication between the Dialysis Unit and Nephrologist in order to prevent or minimize or the risk of dialysis related complications that jeopardize the patients’ well being. It is also clear that the absence of documentation that communication has in fact occurred increases liability in cases of these unfortunate complications.


This medical malpractice article was written by an expert witness working with American Medical Experts, LLC (AME). AME is the nation’s leading source of medical experts for case review and testimony; AME also offers the lowest flat rate fees on Complete Case Reviews ($695) and Expert Witness Reports ($995). For more information, call 888-678-EXPERTS (888-678-3973) or visit AmericanMedicalExperts.com.

Drug Induced Liver Injury DILI - Mechanisms and Liability

Because most medications are metabolized in the liver, Drug Induced Liver Injury (DILI) is frequently the main toxicity of many drugs on the market. Medications can induce DILI either by predictable mechanisms (i.e., acetaminophen) or their toxicity is unpredictable (idiosyncratic DILI). Acetaminophen (Tylenol and similar products) is the main cause of Acute Liver Failure (ALF) in the USA.

The reasons for poor outcomes, such as death or liver transplantation, in acetaminophen ALF are: i] delays in initiating treatment with Mucomyst; ii] incorrect use Mucomyst in either dosage or duration of treatment; iii] use of sedatives and /or narcotics when patients with ALF experience irritability, anxiety, pain or insomnia, which often accelerates the development of coma in ALF; and iv] delays in transferring the patient for Liver Transplantation. Physicians and RNs in Hospitals not familiar with the diagnosis and treatment of acetaminophen ALF or other causes of ALF may be responsible for the progression of the disease. A rapid diagnosis of ALF allows implementation of appropriate management. The liability of the Pharmaceutical Companies is often limited to the inadequate labeling and warning box; this may change since the FDA has considered ‘forcing’ correction of labeling deficiencies.

Medications that induce idiosyncratic DILI are many and the patient’s susceptibility cannot be anticipated. The Hospital liability is similar to that of acetaminophen-induced DILI if the patient presents with ALF. The Pharmaceutical Companies are often found to be liable if the pre-clinical research or the pre-marketing clinical studies shows evidences of a ‘signal’ liver injury that is similar to that observed in the cohort afflicted with the DILI (and ALF). The main issues are related to interpretation of that data including: i] cell toxicity in culture systems and the specificity and relatedness to the human DILI; ii] pharmacokinetics and liver toxicity in animals; iii] evidences of liver injury in clinical studies – even at a relatively low level- ; and iv] evidences of drug-drug or drug-disease interactions that could or should have been inferred.

Although valuable to the medical and scientific community, neither the Med-Watch Reports to the FDA nor the published case reports provide statistical support for the causal association between a medication and ALF. In addition, and except in rare instances (e.g., rechallenge), presumed idiosyncratic DILI cannot be attributed unequivocally to any drug. As evidence of the diagnostic uncertainties, in the United States, the cases of acute liver failure of undetermined causes (17%) exceed those attributed as probable to all medications combined (13%), excluding acetaminophen. Acetaminophen- induced ALF is not associated with chronic liver injury; patients that survive recover completely. In contrast, it has been postulated that liver fibrosis and cancer may result from the liver toxicity in some cases of idiosyncratic DILI. These presumed chronic complications would constitute an extraordinary medical burden to patients treated with that medication. Because these alleged long-term complications of some DILI have significant medical, social, legal, and financial repercussions, is necessary to evaluate the scientific merits of the proposed mechanisms.

About the Expert who prepared the article:

The Gastroenterologist -Liver Expert who wrote this article is a Professor of Medicine and Biomedical Sciences Program and a Full Member of the Comprehensive Cancer Center at the University of California, San Diego. He was a Resident and a Fellow in the Yale University Program and an Expert at the National Institutes of Health. He is Board Certified in both Internal Medicine and Gastroenterology with specific training in Liver Diseases and a former Chairman of the National Research Committee of the American Association for the Study of Liver Diseases.

This Expert has been a Medical and/or Scientific Advisor to the FDA, the National Institutes of Health, the European Union, WHO, Pfizer, Abbott, Wyeth, Eli Lily among others. He has been the main Expert in large class action litigations for Pfizer and Exxon Mobil as well as in individual malpractice cases. The post-hoc feedback from Jurors and Arbitrators has been outstanding.

In addition to clinical and clinical research expertise, this Expert has extensive expertise in basic sciences and pharmacokinetics, valuable assets to assess some medical malpractice cases. The Expert’s research has been founded continuously for 25 years by the NIH and the VA, and received the coveted MERIT Award from the NIH, the Hans Popper Award from the International Society for the Study of Liver Diseases, and the University of California Chancellor’s Award.

He has authored numerous publications, chaired many medical meetings and executed the development of many medical conferences.

This medical malpractice article was written by an expert witness working with American Medical Experts, LLC (AME). AME is the nation’s leading source of medical experts for case review and testimony; AME also offers the lowest flat rate fees on Complete Case Reviews ($695) and Expert Witness Reports ($995). For more information, call 888-678-EXPERTS (888-678-3973) or visit AmericanMedicalExperts.com.

Evaluating Hospital Corporate Responsibilities in Medical Malpractice Cases

Medical malpractice cases require stringent and comprehensive clinical review and attorneys always employ medical experts to review their cases. Often overlooked is the use of a hospital administration expert who can add significantly to the case by evaluating the corporate responsibilities of the hospital involved in the matter.

It is important to utilize a person who has actually worked as a hospital administrator and, indeed, some states require a person actively engaged in the field.

While many physicians feel that they have hospital administrative experience, it may not be adequate to evaluate hospital compliance with accreditation standards, licensure regulations, and administrative policy and procedures. As a person with nearly 40 years of hospital and healthcare administrative experience, I review cases for both defense and plaintiff attorneys and have found this to be of value to all parties involved.

The hospital or healthcare organization always has an interest in every malpractice case as patient safety and the quality of care are central to their mission. Additionally, the discovery of systemic problems, adverse publicity, potential financial loss, and poor staff morale are extremely important to the hospital’s leadership. The attorney can best determine the hospital’s corporate responsibilities through engaging an experienced healthcare executive to evaluate the case.

The administrative expert relies on the physician experts to determine if clinical errors were made and utilizes this information to perform a review of hospital policies and licensure and accreditation standards. The hospital administrative expert will review the appropriate Joint Commission Hospital Accreditation Standards manual to evaluate the degree of compliance of the hospital with the standards. For example, in a case where a wrong site surgery took place, I was able to determine that the hospital did not follow the required Joint Commission standards regarding the identification of the patient and the surgery site, nor did they perform the mandatory time-out procedure prior to starting the operation. Hospital employees could have and should have made certain that the surgeon followed the correct procedures. Clearly, in this case, there were indications of corporate negligence and the hospital had some responsibility in the case.

Another important review performed by the administrative expert is to look at hospital policies and procedures. This evaluation includes determining if the hospital has the required up-to-date policies in place, and then ascertaining if they actually followed them. A case I recently reviewed involved policies for the handling of critical test results and it was readily apparent that the hospital had the required policies in place and that they did follow them when a radiology examination showed a life threatening situation for an emergency department patient. In this case, the hospital followed the accreditation standards and had no corporate liability in the matter.

I am frequently asked to review the credentialing procedures of hospitals to evaluate if they complied with the appropriate standards. This is another often overlooked area of investigation as the hospital must comply with very definitive standards for initial credentialing and re-credentialing physicians and other licensed independent practitioners. It is important to evaluate if the correct procedures were carefully followed, particularly as the standards have been changed in recent years and focus more on an ongoing review process rather than the familiar bi-annual review.

Another area of focus is that of new procedures and new equipment. Did the hospital formally approve the new procedure or the new piece of instrumentation used in the procedure? Were hospital staff members adequately trained in the new procedure? Did the materials management department purchase the new equipment per their policy or did the physician or surgeon bring it in – something I have seen more than most would expect? Have the surgeon’s privileges been expanded to include this new procedure? Many hospitals do this extremely well and others do not. It is important to review this area thoroughly.

Reviewing corporate responsibilities should take place in nearly all medical malpractice cases and can benefit patient care, as well as providing clarity as to the hospital’s compliance with their responsibilities. For many attorneys, the Joint Commission standards are unfamiliar and an administrative expert can assist them in navigating these voluminous and constantly changing standards.

I would also note that a hospital administrative expert can often assist in developing the strategy of the case through explaining the inner workings of the hospital, the internal politics of medical staff relationships, and the rules regarding the use of independent contractors just to name a few. It is usually best to bring the administrative expert into the case as early as possible to help in formulating discovery requests and also in the specific questions to ask hospital representatives in the deposition process.

Much time, effort, and expense can be avoided by utilizing a hospital administrative expert to perform an early review of the case. Both defense and plaintiff attorneys can benefit from this review and assist them in their efforts to resolve the case successfully.

This medical malpractice article was written by an expert witness working with American Medical Experts, LLC (AME). AME is the nation’s leading source of medical experts for case review and testimony; AME also offers the lowest flat rate fees on Complete Case Reviews ($695) and Expert Witness Reports ($995). For more information, call 888-678-EXPERTS (888-678-3973) or visit AmericanMedicalExperts.com.

Hospital Falls - Malpractice Cases

Common issues associated with nurses and hospitals are falls due to the lack of the use of rails. An elderly confused patient, or a patient narcotized with pain medicine or sedatives, requires full length side rails up so they can't fall out of bed.

The same is true for a combative, uncooperative or unstable patient. If the nurses' notes show they did not raise the side rails, or if witnesses, including the roommate, say the rails were not raised, and the patient falls out of bed and injures himself, it's negligence on the part of the hospital and the nurses. (Perhaps physician liability also if the doctor was aware that this was an elderly patient and he failed to write the side rail order.)

Nurses have an independent duty to ensure the safety of their patients, so you have three defendants: the nurse, the hospital and the doctor. The nurses have the independent duty to see whether or not the patient needs side rails and if so, they can and must follow good nursing practice and hospital policy and raise the rails themselves without an order. In fact, when to use side rails is or should be indicated in the hospital rules of almost every hospital, as set forth by the Joint Commission on Accreditation of Hospitals (JCAH). If the hospital accepts elderly Medicare-insured patients, that hospital must be certified by the JCAH, and the JCAH states that with elderly, confused, or drugged patients, side rails must be used.

Were the Nurses Too Busy?

When a patient injures himself, in the hospital, and you claim nursing negligence in failing to supervise and protect the patient, determine how busy the nursing staff was at the time of the incident. Also consider whether they were understaffed. Through discovery obtain the "nursing orders" in effect for all the patients on that nursing unit (floor or ward) and their diagnoses. (You don't need their names.) If the nursing unit was understaffed (by a greedy hospital making a higher profit from lower labor costs), how could your client receive proper nursing care and supervision?

This medical malpractice article was written by an expert witness working with American Medical Experts, LLC (AME). AME is the nation’s leading source of medical experts for case review and testimony; AME also offers the lowest flat rate fees on Complete Case Reviews ($695) and Expert Witness Reports ($995). For more information, call 888-678-EXPERTS (888-678-3973) or visit AmericanMedicalExperts.com.

Methadone Toxicity Wrongful Death Medical Malpractice Case

Methadone is an opioid thought to act by decreasing release of neurotransmitters in the brain resulting in respiratory suppression and, in some cases, death. Several studies have described naive patients who expired shortly after entering methadone maintenance programs which did not adequately assess tolerance prior to initiation of methadone therapy.

Naive users require more time to clear methadone from their bodies placing them at increased risk of overdosing. Liver or kidney dysfunction can greatly prolong methadone clearance resulting in increased risk of adverse effects. Doses of 50 mg or less of methadone have proven fatal to non-tolerant adults. The half-life of elimination of methadone is thought to be about 15 hours, but it could be as long as 55 hours in some cases. Autopsies have shown average blood concentrations of 0.28 mg/L with a range of 0.06 to 3.1 mg/L in 59 victims versus 0.11 mg/L in methadone maintenance patients.

About the expert who provided this information:

While I have been president and principal toxicologist for the past 26 years, my consultancy has offered independent consulting services providing litigation support for both the plaintiff and defense in matters related to causation. We have participated in cases involving solvents such as trichloroethylene (TCE) and benzene, welding fumes, heavy metals such as hexavalent chromium, lead, arsenic, manganese and nickel, pesticides such as methyl parathion, lindane, chlorpyrifos, and diazinon, prescription and OTC drugs such as Baycol, Vioxx, phenylpropanolamine (PPA) and other Ephedra alkaloids, Pantopaque and Fen-Phen, industrial chemicals such as creosote, PCB’s, dioxins, arsenic, PVC and vinyl chloride monomer, irritant gases such as chlorine, ammonia, and sulfur dioxide, hazardous waste sites, alcohol (DUI), illicit drugs, tobacco smoke and breast implants, among others. We have been involved heavily in health/exposure assessment surveys of large populations including sampling of blood, urine, and hair and have organized efforts and experts to address the complex problems of mass tort litigation.

This medical malpractice article was written by an expert witness working with American Medical Experts, LLC (AME). AME is the nation’s leading source of medical experts for case review and testimony; AME also offers the lowest flat rate fees on Complete Case Reviews ($695) and Expert Witness Reports ($995). For more information, call 888-678-EXPERTS (888-678-3973) or visit AmericanMedicalExperts.com.

How to Increase Recovery in Your Medical Malpractice Cases - Keep the Hospital in the Case

Medical malpractice cases obviously require clinical review and lawyers realize that they must employ medical experts to review their cases. Often overlooked is the use of a hospital administration expert who can add significantly to the case by looking at the corporate responsibilities of the hospital. Adding this type of expert to your team provides the opportunity to increase your recovery by including the mandated insured capacity of the hospital in the case. In addition, the hospital always has an interest in the results of the case and can provide leverage on the involved physicians as the case moves forward.

Adverse publicity, as well as potential financial losses, are both extremely important to the hospital leadership. The attorney can best determine the hospital’s responsibility through employing an experienced hospital administrator to evaluate the case.

The administrative expert relies on the physician experts to determine if clinical errors were made and utilizes this information to determine what hospital policies and licensure and accreditation standards were violated as well. A seasoned hospital administrator will review the appropriate Joint Commission on Accreditation of Health Care Organizations (JCAHO) manual to evaluate the degree of compliance of the hospital with the standards. For example, in a recent case where a wrong site surgery took place, I was able to determine that the hospital did not follow the required JCAHO standards for identifying the patient and the surgery site, nor did they perform the required time-out procedure prior to starting the operation. Had hospital employees made certain that the surgeon followed the correct procedures, the entire incident would have been avoided. Clearly, in this case, corporate negligence took place and the hospital was certainly a party to the case. Ultimately, this case had a much higher recovery then it would have if only the surgeon was pursued.

Another important review performed by the administrative expert is to look at hospital policies and procedures. This evaluation includes determining if the hospital has the required policies in place, and then ascertaining if they actually followed them. A recent case I reviewed looked at policies regarding the handling of critical test results and it became apparent that the hospital neither had a policy in place as they should have nor did they follow the required procedures when a radiology examination showed a life threatening situation for an emergency department patient . Again, the hospital had committed a violation of accreditation standards and had liability in the matter.

I am frequently asked to review the credentialing procedures of hospitals to evaluate if they complied with the appropriate standards. This is another often overlooked area of investigation as the hospital has strict standards they must follow in credentialing and re-credentialing physicians and other independent practitioners, and in determining their privileges. It is very common to find that steps were skipped as the processes very often become rote as hospital staff perform this important task. I look at such things as the composition of the credentials committee. Was the appropriate clinical specialist involved in evaluating the applicant physician? Did they collect all of the required original documentation? Did they truly follow their own credentialing policies?

A particular area of interest is that of new procedures. Did the hospital actually approve the new procedure or new piece of instrumentation used in the procedure? Were hospital staff trained in the new procedure? Did the materials management department purchase the instrument per their policy or did the surgeon bring it in? Were the surgeon’s privileges expanded to include this new procedure? It is amazing to see how many times the hospital does not do this correctly and then finds the physician is involved in a malpractice case.

Utilizing a hospital administrative expert can strengthen the case. The hospital, through its board and management, has significant impact on the quality of care delivered by its medical and nursing staff and has the ability to reduce medical errors by holding staff accountable to their policies and standards. Reviewing this should take place in most medical malpractice cases and can benefit and improve patient care for all, as well as providing an additional and large source of funds for the patient who was injured.

For many attorneys, the JCAHO standards are unfamiliar and a hospital administrative expert can assist them in navigating these voluminous and sometimes confusing standards. I would also note that a hospital administrator can often assist in the strategy of the case through explaining the inner workings of the hospital, the internal politics of medical staff relationships, and the rules regarding the use of independent contractors. It is usually best to bring the administrative expert into the case as early as possible to help determine what is asked for in discovery and also in the types of questions to ask hospital representatives in the deposition process.

Add a hospital administrative expert to your team and strengthen your case and increase your recovery for your clients.

This medical malpractice article was written by an expert witness working with American Medical Experts, LLC (AME). AME is the nation’s leading source of medical experts for case review and testimony; AME also offers the lowest flat rate fees on Complete Case Reviews ($695) and Expert Witness Reports ($995). For more information, call 888-678-EXPERTS (888-678-3973) or visit AmericanMedicalExperts.com.

Tubal Ligation Sterilization Causing Intestine Perforation

Laparoscopic tubal ligation surgery is performed through a narrow pipe inserted into the abdomen. Either a clip is placed across each fallopian tube, or it is cauterized (burned by the passage of electricity through a segment of each tube, causing it to char and seal).

Decades ago the electrocautery was of the “unipolar” design. This allowed the electricity to enter through the active electrode, while the current returned to the device through the body, and then via a ground electrode under the thigh. Unfortunately, the electric current had the risk of arcing into the nearby small intestine, burning a hole into this hollow organ.

That would result in its leakage causing peritonitis (intra-abdominal infection) requiring emergency surgery.

The modern devices are called “bipolar” because the electric current flows only between each side of the pliars-like grasping instrument. Intestinal burns should never occur. If that happens, it is either from the surgeon negligently touching the metal end to the intestine, or the electrocautery was defective and not properly maintained by the hospital.

This medical malpractice article was written by an expert witness working with American Medical Experts, LLC (AME). AME is the nation’s leading source of medical experts for case review and testimony; AME also offers the lowest flat rate fees on Complete Case Reviews ($695) and Expert Witness Reports ($995). For more information, call 888-678-EXPERTS (888-678-3973) or visit AmericanMedicalExperts.com.

Gallbladder Surgery Causing Serious Liver Injury

The gallbladder stores bile between meals. It concentrates the bile by absorbing water. That increases the risk for gallstones to form. These cause severe inflammation and pain.

When the gallbladder contracts after a fatty meal (where its bile is used to help in the digestion of fat), its contraction can also cause pain from gallstones.

During Gallbladder surgery (cholecystectomy) preventable injury can result in damage to the main (common) bile duct that connects the liver with the gallbladder and first part of the small intestine (duodenum).

The gallbladder is attached to the under surface of the liver. Its lowermost end drains into a narrow tube (the cystic duct). The cystic duct drains directly into the main bile duct. Before the cystic duct is cut, the surgeon must identify the main (common) bile duct. Injury to the common bile duct is a disaster, because if it is immediately repaired at that time, it often heals with severe scare tissue formation that can cause a blockage of bile flow. This impaired bile flow also increases the risk of a potentially fatal infection (cholangitis), as well as liver failure (obstructive jaundice).

If the surgeon attempts to perform the cholecystectomy operation using the laparoscopic instruments and cannot accurately discern the junction of the cystic duct with the common bile duct, then he must stop and perform the incision to open up the abdomen (laparotomy), and proceed under direct vision and feel.

Severing the common bile duct and not recognizing that injury is even more egregious. The patient will develop progressive yellow jaundice and liver failure from the ligated (tied or clipped) common bile duct. The surgery to repair that injury requires a great skill. A segment of the small intestine (jejunum) is used as a conduit between the remaining upper portion of the common bile duct and the intestines. But this connection (anastomosis) frequently scars closed requiring a lifetime of repetitive operations and serious risk of liver duct infections (cholangitis).

In addition to the danger of injury to the common bile duct, the hepatic (liver) artery also is located at the lowermost section of the gallbladder and must be properly identified and protected. It must not be ligated instead of the cystic (gallbladder) artery. Otherwise, liver failure could result, causing death from a gangrenous liver.

This medical malpractice article was written by an expert witness working with American Medical Experts, LLC (AME). AME is the nation’s leading source of medical experts for case review and testimony; AME also offers the lowest flat rate fees on Complete Case Reviews ($695) and Expert Witness Reports ($995). For more information, call 888-678-EXPERTS (888-678-3973) or visit AmericanMedicalExperts.com.

Air Embolism Medical Malpractice

With intravenous therapy there is a risk of air embolism, that is, air bubbles entering the vein system from the failure to have the fluid fill up the entire plastic line prior to connection to the catheter or needle. Sometimes the intravenous bottle will run dry, and the nurse will connect another bottle without observing a substantial amount of air in the line. This air can cause damage by entering the heart, and if in a significant amount, obstruct blood flow through the heart into the lungs, somewhat like a blood clot in a pulmonary embolism.

The emergency treatment is placing the patient on their left side downward (with the body tilted in a leg upward, head downward position). This removes the air bubble from the tricuspid and pulmonic valve openings, allowing blood to go through its circuit to the lungs, while the air bubble is in a more innocuous position at the very bottom portion of the heart (apex), where it will be absorbed slowly over a few hours.

Sometimes a patient will have a congenital type of heart disease where there is a communication between the right atrium and left atrium, bypassing the filtering circuit of the lungs. Air entering the right atrium with this congenital heart defect can go directly into the left atrium when there is this "right to left" shunt flow of blood, and from there into the left ventricle and out into the aorta, the main artery of the body. If these air bubbles enter the cerebral circulation (the arteries to the brain) this will result in a stroke. Entering the blood vessels in other portions of the body usually is not serious as most areas of the body's flesh can withstand a number of hours of oxygen deprivation while the air bubbles are absorbed. The brain, however, can only withstand a few minutes of absence of oxygen before irreversible damage occurs.

This medical malpractice article was written by an expert witness working with American Medical Experts, LLC (AME). AME is the nation’s leading source of medical experts for case review and testimony; AME also offers the lowest flat rate fees on Complete Case Reviews ($695) and Expert Witness Reports ($995). For more information, call 888-678-EXPERTS (888-678-3973) or visit AmericanMedicalExperts.com.

Cancer Pain Management Negligence

Safe and effective chronic opioid therapy for chronic cancer related pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion.

Although evidence is limited in many areas related to use of opioids for chronic non-cancer pain, several guidelines provide recommendations developed by multidisciplinary expert panel after a systematic review of the evidence.

Generally, narcotics are not the only modality that can be used to treat pain. Adjuvant therapies together with narcotics can be very helpful. For example, steroids and non-steroidal anti-inflammatory drugs, such as ibuprofen(Advil) can reduce the inflammation associated with tumors pressing on tissues, and certain anti-depressants and anti-seizure drugs can modify how the brain perceived pain and lessen it. There are also procedures, such as nerve blocks, that can be helpful when pain is localized.

Cancer pain can require very high doses of narcotics. Guidelines provide guidance and in some case, recommend a specialty pain management consultation. A diagnostic re-evaluation is often indicated to exclude cancer progression. If there is progression, the best pain management is successful treatment of the underlying disease. It may sometimes be possible to switch to a different narcotic, which reduces tolerance and allows a lower dose, or decrease total narcotic dose by using adjuvant analgesics, steroids or neuro-modifiyng drugs discussed above, but there remain situations in which very high doses are required despite all efforts.

Risk of addiction in cancer patients is very low, around 2% (Friedman et al), but several instruments can reduce it even farther: CAGE questionnaire, Cyr-Wartman Screen, Skinner Trauma Screen, Screener and Opioid Assessment for Patients. It is important to understand the distinction between addiction, a psychological syndrome, and habituation, which is the body getting used to narotics and requring higher doses. Habituation can be easily treated; addiction is much more difficutl to treat. Unfortunately, overrated fear of addiction or unwarranted anxiety about attracting the attention of the DEA, sometimes leaves patients with inadequate pain control.

Failure to provide adequate pain control to cancer patients is a deviation from the standard of care and can be grounds for a malpractice suit, or it can play a role in increasing recovery. The use of national guidelines or local state policies can be helpful to both plaintiff and defense. State pain policies can shield practitioners who have complied with the state policy, or a damn physician who have not. Some state policies are so restrictive that they automatically put the defendant at a disadvantage. An expert who is familiar with the use of guidelines and local policies can prove invaluable in the litigation of cases the involve standards of pain management.

References:

Davis MP, Weissman DE, Arnold RM, Opioid dose titration for severe cancer pain: a systematic evidence-based review.J Palliat Med. 2004 Jun;7(3):462-8.
Washington State Agency Medical Directors' Group. Interagency guideline on opioid dosing for chronic non-cancer pain: an educational aid to improve care and safety with opioid treatment. Olympia (WA): Washington State Department of Labor and Industries; 2010. 55 p. [123 references].
Friedman DP. Perspectives on the medical use of drugs of abuse. J Pain Symptom Manage 1990; 5: S2-S5. Joranson DE, Gilson AM, Dahl JL, Haddox JD. Pain management, controlled substances, and state medical board policy: A decade of change. J Pain Symptom Manage. 2002;23:138-147.
Furrow BR. Pain management and provider liability: No more excuses. J Law Med Ethics. 2001;29:28-51.
Ziegler SJ, Lovrich NP Jr. Pain relief, prescription drugs, and prosecution: A four-state survey of chief prosecutors. J Law Med Ethics. 2003;31:75-100.

Biography:

The Hematologist/Oncologist who wrote this article had been Associate Professor of Medicine while a full-time attending at the University Hospital of a Medical School until 2009. Prior to 2004 had been an Associate Clinical Professor of Medicine. He is currently in private practice. He is first author of over thirty academic articles, chapters and several books. Over the past two decades he held the positions of Interim Chief of Hematology and Oncology, Director of the Cancer Center, Chief of Hematology and Oncology and Chief of Service and concurrently Director of the Cancer Center Network of the Health and Hospitals Corporation and Co-Director of Oncology at a University Hospital and Medical Center. He developed and ran two clinical research programs as well as a community advocacy group, a consulting group, and a non-profit educational institution. In addition to Internal Medicine and Oncology. He is Board Certified in Quality Assurance and Utilization Review and holds an MBA. He was listed several times as the best in his specialty by the Castle Connolly Guide to America's Top Doctors.

This medical malpractice article was written by an expert witness working with American Medical Experts, LLC (AME). AME is the nation’s leading source of medical experts for case review and testimony; AME also offers the lowest flat rate fees on Complete Case Reviews ($695) and Expert Witness Reports ($995). For more information, call 888-678-EXPERTS (888-678-3973) or visit AmericanMedicalExperts.com.

The Emergency Department and Corporate Responsbility

The evaluation of patient care in the hospital emergency department often focuses only on the care itself and the practitioners that delivered that care. Too often, the responsibilities of the hospital in providing that care is overlooked or not looked at from the perspective of their corporate responsibilities. This is where a Hospital Administration Expert will answer those questions and fill the need from the corporate perspective.

It is usually well understood that the hospital must comply with the standards promulgated by federal, state, and local authorities, including such things as the federal Emergency Medical Treatment and Active Labor Act and regional trauma regulations; the hospital must also comply with the standards of the Joint Commission if they are an accredited hospital.

These Joint Commission standards are widely accepted in the United States as the standard of care for the provision of inpatient and ambulatory hospital care, and describe the accountability and responsibility of hospital leaders in the delivery of care at their facilities. Joint Commission standards require that hospital leaders establish a governance structure and management systems to oversee that appropriate rules, regulations, infrastructure, credentialing, and communication processes are in place to deliver high quality and safe care to their patients. The hospital is further required to establish systems to monitor the effectiveness of care and to correct any deficiencies. Ultimately, the hospital is responsible for the oversight of all professional services provided by its medical staff, employees, and any others that it credentials or contracts with to practice at the hospital, including emergency department contract physicians. Joint Commission standards are also used by the federal Centers for Medicare and Medicaid to determine compliance with the requirements of these programs, and are also used and accepted as the standard of care for hospital licensure in many states.

It is increasingly common for hospitals to contract for emergency department physician services and presume that the contract with the physician company addresses all their responsibilities. This is not the case, as the hospital remains responsible for all patient care services that take place, and they must have the required policies and procedures in place to direct that care and, most importantly, must make certain that those policies are followed by the contract staff and all hospital employees as well.

In the emergency department, these policies often focus on such things as timely care, accurate performance of diagnostic tests, and the communication of critical test result information to clinicians and patients. A common problem that occurs is the test result that comes back after the patient is discharged that is never communicated to the patient or their primary care physician. Another situation that may happen in many smaller hospitals is the use of part-time staff to read test results and this may be delayed due to the hours that the staff is present.

In the evaluation of emergency department cases, it is recommended that risk managers and legal counsel, both defense and plaintiff, look at whether the hospital has fulfilled their corporate responsibilities in providing care and not just look at the medical care itself.

This medical malpractice article was written by an expert witness working with American Medical Experts, LLC (AME). AME is the nation’s leading source of medical experts for case review and testimony; AME also offers the lowest flat rate fees on Complete Case Reviews ($695) and Expert Witness Reports ($995). For more information, call 888-678-EXPERTS (888-678-3973) or visit AmericanMedicalExperts.com.

Mild Hyponatremia: new risk of memory changes, gait disturbances and death

Hyponatremia: Hyponatremia is defined as a lower than normal serum sodium concentration using routine laboratory testing of serum electrolytes. Although chronic hyponatremia below 120 mEq almost universally prompts medical investigation, milder forms are usually overlooked or disregarded as being of little clinical significance. Recently, mild-moderate hyponatremia (i.e., a serum sodium concentration >125-135 mEq/L) has been associated with distinct symptoms as well as with increased mortality after hospitalization.

What causes hyponatremia? Many conditions are associated with chronic hyponatremia, the single most common electrolyte abnormality. These include inflammation in the brain or lung, cancers, thyroid disease, kidney disease, heart failure, and several categories of medications such as oral hypoglycemics (used in patents with diabetes mellitus), narcotics, diuretics, and antidepressants, particularly those agents referred to as selective serotonin receptor inhibitors (SSRI agents).

What are the consequences of mild hyponatremia? Recent epidemiologic evidence associates mild hyponatremia (average 131 mEq/L) with impairment of short-term memory as well as an abnormal gait. While both deficits are concerning, the risk of fall is significant (more than double compared to patients with a normal serum sodium), especially in the elder population at greatest risk for hip and femoral fractures.

Standard of Care: Serum sodium should be evaluated in all patients receiving routine laboratory testing for serum electrolytes, glucose and kidney function. The finding of a serum sodium concentration below 135 mEq/L should prompt inquiry for associated changes in short-term memory, as well as an evaluation of gait. If either are implied, a search for the cause of hyponatremia is important in normalizing these parameters, thereby potentially reducing the risk of short-term memory loss, the likelihood of falling due to an unsteady gait, and decreasing the risk of mortality, particularly in patients with underlying chronic disease conditions.

References:

1. Hufschmidt A, Shabarin V, Zimmer T. Drug-induced confusional states: the usual suspects? Acta Neurol Scand. 2009;120(6):436-8.
2. Sandhu HS, Gilles E, DeVita MV, Panagopoulos G, Michelis MF. Hyponatremia associated with large-bone fracture in elderly patients. Int Urol Nephrol. 2009;41(3):733-7.
3. Waikar SS, Mount DB, Curhan GC. Mortality after hospitalization with mild, moderate, and severe hyponatremia. Am J Med. 2009;122(9):857-65.

About this Expert:

The Nephrologist Expert who wrote this article is an Associate Professor of Medicine and an attending physician in the Renal Section. His interests include education of medical students and house staff, basic research on the cellular mechanisms of ischemic acute renal failure and the care of patients with both general medical and renal diseases. This Expert is the senior author of numerous publications in the area of the cellular stress response to acute renal ischemia and has been a Principal Investigator for the National Institutes of Health for almost 20 years. He also received several awards for excellence in teaching from medical students, house staff and colleagues. Most recently, he was a finalist for the Metcalf Teaching Award for full-time faculty and received the Grant V. Rodkey award from the Medical Society for significant contributions to medical student education and mentoring. This expert has been involved in the care of complex internal medicine and nephrology patients for more than 25 years in both private practice and university hospital settings.

This medical malpractice article was written by an expert witness working with American Medical Experts, LLC (AME). AME is the nation’s leading source of medical experts for case review and testimony; AME also offers the lowest flat rate fees on Complete Case Reviews ($695) and Expert Witness Reports ($995). For more information, call 888-678-EXPERTS (888-678-3973) or visit AmericanMedicalExperts.com.

Prostate Cancer - Delay in Diagnosis, Failed Follow-up Strategy

Attorneys are often consulted by patients who feel that they have not been properly followed after cancer had been treated and that a recurrence could have been diagnosed earlier but was missed. Different cancers have different follow-up recommendations. For prostate cancer, PSA is the mainstay of the follow-up strategy.

One consequence of the routine adoption of PSA monitoring after treatment of early stage prostate cancer is the identification of men with a PSA-only recurrence. In this situation, increases in serum PSA over the pretreatment baseline are often not accompanied by signs or symptoms of progressive disease. When PSA rises, the physician is often faced with a quandary. The longer one waits to perform an imaging study, the greater the chance that a recurrence can be confirmed and treatment started. On the other hand, imaging too early in the course of PSA rising, might result in a negative study, frustrated patient, avoidable expense and the need to repeat imaging at a future time. If the rise in the PSA is slow and occurs after a prolonged period, the site of relapse is generally at the site of the original tumor. Since a significant number of these men are relatively young and otherwise healthy and can still be cured, intense interest has been focused upon their treatment, with particular attention to survival, and the impact of therapy on quality of life.

Treatment options for men with a PSA-only recurrence after radical prostatectomy include external beam radiation therapy (RT) to the prostatic bed with or without treatment of the pelvic lymph nodes (salvage RT), androgen deprivation therapy (ADT), a combination of salvage RT plus ADT, or observation. Most of the available data regarding these approaches has come from observational series. Long-term results of randomized clinical trials will be required to define the optimal approach.

After prostatectomy, PSA should be 0.0 or close to zero. Rising PSA suggests recurrence even if the absolute PSA values is low. When this fact is not appreciated, a recurrence can be missed because the PSA, although higher, is still within the “normal” range. There is some controversy on whether any PSA rise warrants re-treatment or whether the PSA Velocity (rate of PSA rise over time) should be used to predict when to intervene.

References:

Wiegel T, Lohm G, Bottke D, et al. Achieving an undetectable PSA after radiotherapy for biochemical progression after radical prostatectomy is an independent predictor of biochemical outcome--results of a retrospective study. Int J Radiat Oncol Biol Phys 2009; 73:1009.
Trock BJ, Han M, Freedland SJ, et al. Prostate cancer-specific survival following salvage radiotherapy vs observation in men with biochemical recurrence after radical prostatectomy. JAMA 2008; 299:2760.
Boorjian SA, Karnes RJ, Crispen PL, et al. Radiation therapy after radical prostatectomy: impact on metastasis and survival. J Urol 2009; 182:2708.
Andrew J. Stephenson, Salvage Radiotherapy for Recurrent Prostate Cancer After Radical Prostatectomy , JAMA. 2004;291:1325-1332

Biography:

The Hematologist/Oncologist who wrote this article had been Associate Professor of Medicine while a full-time attending at the University Hospital of a Medical School until 2009. Prior to 2004 had been an Associate Clinical Professor of Medicine. He is currently in private practice. He is first author of over thirty academic articles, chapters and several books. Over the past two decades he held the positions of Interim Chief of Hematology and Oncology, Director of the Cancer Center, Chief of Hematology and Oncology and Chief of Service and concurrently Director of the Cancer Center Network of the Health and Hospitals Corporation and Co-Director of Oncology at a University Hospital and Medical Center. He developed and ran two clinical research programs as well as a community advocacy group, a consulting group, and a non-profit educational institution. In addition to Internal Medicine and Oncology. He is Board Certified in Quality Assurance and Utilization Review and holds an MBA. He was listed several times as the best in his specialty by the Castle Connolly Guide to America's Top Doctors.

This medical malpractice article was written by an expert witness working with American Medical Experts, LLC (AME). AME is the nation’s leading source of medical experts for case review and testimony; AME also offers the lowest flat rate fees on Complete Case Reviews ($695) and Expert Witness Reports ($995). For more information, call 888-678-EXPERTS (888-678-3973) or visit AmericanMedicalExperts.com.

How To Locate The Ideal Physician Assistant Expert Witness For Your Medical Malpractice Case

Generally, when a medical malpractice case involves a physician assistant, the attorney will need a physician assistant with the same or similar clinical experience as the physician assistant whose care is at issue. There are some jurisdictions that will permit a physician to offer standard of care opinions concerning physician assistants if they have employed, worked with, supervised or taught physician assistant students.

The standard of care requires that the physician assistant provide any task delegated to him at the same level of competency as the delegating physician. Despite the fact that this standard must be equal for both providers a PA may not, simply by the nature of his dependent provider status, offer expert testimony concerning the standard of care of a physician.

Physician Assistants are generally retained by counsel concerning standard of care. Occasionally causation opinions are requested and permitted by the court.

It can be of benefit for counsel to retain a physician assistant (or any expert) in the early stages of a case. Many times I have been retained as the deadline for designating experts is fast approaching, therefore the issues of the case have been framed, pleadings and motions filed and discovery is in progress or has been completed. Retention of an expert early in case assessment provides the attorney with the opportunity to apprise the expert of the details of the case and obtain an objective evaluation of the case materials, thus permitting the expert to offer comments and suggestions that the attorney may not have considered since medicine is not the attorneys profession. This can assist in framing the issues and identify areas where the standard of care has been violated and explain why those violations are pertinent.

I have always held the tenet that every question an attorney asks during a deposition has a purpose. Discovery Depositions are not fishing expeditions. As such, retaining an expert early can benefit the attorney in developing target discovery and assistance in suggesting areas to be explored during the opposing expert’s deposition.

Do I Want This PA as my Expert?

Attorneys determine which expert they will retain based on very individual preferences. Comfort level, clinical experience, cost, distance, prior deposition and trial experience are only a few. Some cases are so evident that simply obtaining an Affidavit of Merit and an expert opinion will lead to arbitration and eventual resolution.

Most attorneys would agree that no case is assured based on a single deposition but some have been lost due to an injurious deposition. As such, evaluating a potential expert witness physician assistant goes well beyond searching the internet, looking at a pile of resumes or calling an Expert Witness Agency. Every attorney has his or her own “comfort level” concerning experts which is why some firms use the same expert on more than one occasion. Key elements in considering an expert should include credentials, licensure, clinical experience, communication, and creditability. The first three are obvious requirements. Credentials, while imperative, generally have limited influence on a jury especially if the credentials are not directly germane to the issue at hand. Surveys have demonstrated that most jurors feel that the credentials of most experts “cancel each other out”.

It has been quoted before (Harry Beckwith “The Invisible Touch”) “Communication is not a skill, it is the skill”. Being an expert means to educate the court and jury, in layman’s terms, concerning the matters at hand in a clear and concise manner. At the conclusion of the expert’s testimony the jurors should have a clear understanding of the opinions stated by the expert.

Credibility is not only determined based on fact but also on impression. Once the expert has passed the Court’s scrutiny it is the impression of the jury that ultimately determines creditability. In order for an expert to present himself/herself as a credible witness it requires meticulous preparation, an opinion founded on evidence based medicine and not supposition, a relaxed yet professional demeanor, and a calm presentation style. The expert should be adaptable to the various methods of cross examination utilized by experienced trial lawyers and be firm and direct in his/her opinions while avoiding an argumentative environment. This often times requires a delicate balance.

The “Smoking Gun”:

It behooves the retaining attorney to investigate an expert who is going to be retained. We are all aware of the “expert witness” who has inflated his/her credentials or has skeletons in their closet... www.ncccpa.net will immediately verify a physician assistant’s certification status and many states offer websites that permit the average citizen to verify a provider’s active license status and any disciplinary actions, active or past. Such sites as the “Daubert Tracker”, LexisNexis, Westlaw and CourtLink can provide additional valuable information.

Retaining the Jury’s Attention:

Droopy eyes, blank stares, scribbling on note books. All signs that the jury isn’t listening. None of this is intentional. The vast majorities of jurors have never served before and take their responsibility seriously. However, the fact remains that their full attention is required for an expert to successfully convey his/her opinions. At times this can be difficult to achieve, especially after lunch and mid-afternoon.

So what does an expert do to retain a jury’s attentiveness? Build a relationship with the jurors. Speak clearly, specifically and directly at the jury. Make eye contact with as many as possible, have your seat facing the people you’re talking to and do not speak in a monotonous tone. Adopt a persuasive appearance and avoid a defensive posture during cross examination.

Effective experts are those who understand the jury is not expected to accept an opinion simply because the court has permitted them to offer one. Experts are those who understand the jury’s right to a solid opinion established on evidence based medicine and honesty. Effective communication skills are paramount for any expert addressing the court and jury.

Physician Assistants have been involved in the American Health Care Systems for over forty years. The American Academy of Physician Assistants was founded in 1968 as the official body representing the profession with a mission “to provide quality cost effective, accessible health care and to promote the profession and personal development of physician assistants”. There are more than 140 physician assistant programs in the United States. The U.S. Bureau of Labor Statistics (BLS) projected that physician assistant employment opportunities will grow 50% by 2014. This will make it the fourth fastest growing profession in the country.

Physician assistants are either licensed or registered in every state in the union including Puerto Rico, Guam the District of Columbia and the Virgin Islands and have prescriptive authority in every jurisdiction. Forty‐four states allow PAs to prescribe controlled substances. PAs are required to register with the Drug Enforcement Agency and possess a valid DEA number to prescribe controlled medication.

The U.S. Bureau of Labor Statistics (BLS) projected that physician assistant employment opportunities will grow 50% by 2014. This will make it the fourth fastest growing profession in the country.

As the profession continues to mature and its contribution in the medical arena expands the need for physician assistant expert witnesses is also expected to increase.

Expanding Scope of the Physician Assistant Profession:

At its initial inception the physician assistant was envisioned as an extension of the general practitioner. However, this is far from the role of the physician assistant in today’s Health Care System. Today PAs practice in every medical specialty. Recently the National Commission of the Certification of Physician Assistants announced that applications for “Specialty Certificates of Added Qualifications” (CAQs) are being accepted. There are presently five areas open for CAQs: Cardiovascular/Thoracic Surgery, Emergency Medicine, Nephrology, Orthopedic Surgery and Psychiatry. Visit the National Commission on Certification of Physician Assistants web site www.nccpa.net for the requirements individual physician assistants must fulfill to achieve these advanced certificates.

The PA expert who wrote this article has been a physician assistant for 36 years and actively practice in family practice, urgent care, emergency medicine as well as correctional medicine. He has been involved as an expert witness for 17 years and has testified 7 times both in State and Federal Court and have provided approximately 40 Depositions. He reviews cases for both plaintiff and defense attorneys. He has provided testimony in 10 states. He attended college at the University of Chaminade in Honolulu obtaining by BA Degree in Psychology and attended his physician assistant training in what is now referred to as the University of Detroit Mercy where he obtained his second Bachelors Degree. As part of his last rotation in PA school he did an eight week preceptorship in Addison. He has had two jobs as a PA. He is a Member of the American Academy of Physician Assistants and the Michigan Academy of Physician Assistants. He is Board Certified by the National Commission on the Certification of Physician Assistants and has been continually certified since graduation. PAs are required to take a re -certification test every six years to maintain the ability to use the initial "C" for certified after their names.

This medical malpractice article was written by an expert witness working with American Medical Experts, LLC (AME). AME is the nation’s leading source of medical experts for case review and testimony; AME also offers the lowest flat rate fees on Complete Case Reviews ($695) and Expert Witness Reports ($995). For more information, call 888-678-EXPERTS (888-678-3973) or visit AmericanMedicalExperts.com.

Pancreatitis associated with ERCP

Endoscopic retrograde cholangiopancreatography (ERCP) remains the most common cause of iatrogenic pancreatitis [1]. Studies have shown post-ERCP complications were responsible for greater than 65 percent of malpractice claims [2, 3].

A recent autopsy study showed that more than half the deaths associated with ERCP were due to iatrogenic pancreatitis [4]. Historically the rates of pancreatitis associated with ERCP have ranged from 1.6-15.1 percent. Most cases of pancreatitis are mild however approximately 1 percent of cases may result in severe complications including death. There are many risk factors which have been identified which are predictive of an individual having an increased likelihood of developing post ERCP pancreatitis. The most common patient risk factors associated with an increased risk of pancreatitis after ERCP include female gender, younger age, sphincter of Oddi dysfunction and recurrent unexplained pancreatitis [5]. Procedure related factors include performance of Sphincter of Oddi manometry, performance of a sphincterotomy, difficult cannulation and balloon sphincteroplasty [5].

The presence of one or more of these factors significantly increases the likelihood that an individual will develop pancreatitis and should prompt appropriate caution in the operator.

In an attempt to reduce the incidence of pancreatitis after ERCP the National Institutes of Health held a consensus in 2002 [6]. The recommendation of the NIH panel was that there was no longer a need for diagnostic ERCP except in few special circumstances. As a result of these recommendations diagnostic ERCP has been replaced by the performance of MRCP. . At our institution the need for performance of diagnostic pancreatography via ERCP has been replaced by MRCP with secretin. Secretin MRCP provides a method for evaluating the pancreatic ductal anatomy which is not dependent on the skill of an ERCP operator. This advantage makes it the procedure of choice for evaluating the pancreatic ductal anatomy in subjects with complex biliary anatomy such as Bilroth II anastomoses. Sphincter of Oddi manometry remains one of the only procedures in which diagnostic ERCP is recommended. Sphincter of Oddi manometry has the highest risk of causing pancreatitis of any procedure performed during ERCP. The indications for performing this intervention must be clearly defined and explicit because most individuals will have approximately a 1 in 5 chance of developing pancreatitis after this procedure. It is extremely important to characterize the type of sphincter of Oddi dysfunction being investigated because only type I and some type II SOD patients should undergo diagnostic ERCP.

In summary, the risk of pancreatitis after ERCP is a common but highly preventable complication of the procedure. Factors which may reduce the risk include the experience of the operators and careful screening of patients prior to the procedure. High risk patients should also be evaluated by an experienced clinical pancreatologist who can assist in pre-procedural risk stratification.

References:

1. Cotton P et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointestinal Endoscopy 1991; 37:383.
2. Rabenstein T et al. 25 years of endoscopic sphincterotomy complications in Erlangen: assessment of the experience in 3,498 patients. Endoscopy 1998;30:A194.
3. Trap R et al. Severe and fatal complications after diagnostic and therapeutic ERCP: a prospective series of claims to insurance covering public hospitals. Endoscopy 1999; 31:125.
4. Cotton, PB. Analysis of 59 ERCP lawsuits; mainly about indications. Gastrointestinal Endoscopy 2006; 63:378.
5. Freeman, ML et al. Risk factors associated for post-ERCP pancreatitis: a prospective, multicenter study. Gastrointestinal Endoscopy 2001; 54: 425.
6. http://consensus.nih.gov/2002/2002ERCPsos020html.htm

Author bio:

This Gastroenterology Expert is co-director of the Pancreas Center in Boston, a Harvard teaching hospital. He is an Assistant Professor of Medicine at Harvard Medical School and also sees patients at a local community hospital in MA. He is a national and international expert in the fields of acute and chronic pancreatitis. His duties include evaluation and management of complex pancreatitis, pancreatic cystic disease and pancreatic cancer. He has won numerous awards including the American College of Gastroenterology Governors for excellence in clinic research. He is available for expert clinical case review, expert witness reports and consultation starting at our greatly reduced rates found on our Web site.

This medical malpractice article was written by an expert witness working with American Medical Experts, LLC (AME). AME is the nation’s leading source of medical experts for case review and testimony; AME also offers the lowest flat rate fees on Complete Case Reviews ($695) and Expert Witness Reports ($995). For more information, call 888-678-EXPERTS (888-678-3973) or visit AmericanMedicalExperts.com.

Role of Joint Commission on Accreditation of Healthcare Organizations Standards in Med Mal Cases

Lawyers often ask me to explain how I use the JCAHO standards in evaluating medical malpractice cases and whether this evaluation will assist them in their pursuit of justice for their clients. I usually start my explanation with a brief history of the Joint Commission and its role in hospital operations and reimbursement.

The JCAHO was formed in 1951 by several professional organizations: the American Hospital Association, the American College of Physicians, the American College of Surgeons, and the American Medical Association. Its mission is “To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value”.

To accomplish this mission, the JCAHO has developed standards for accrediting hospitals and other types of healthcare organizations that focus on the delivery of the highest possible quality patient care as well as ensuring a safe environment for patients and staff. While a hospital’s participation in the JCAHO accreditation is technically voluntary, the federal government requires hospitals to meet their standards in order to receive reimbursement from the Medicare and Medicaid programs. Obviously, this requirement essentially mandates that all hospitals meet the JCAHO standards or one of the few other organizations that are included in this payment mandate. While the process is voluntary, it is important to understand that the standards are mandatory and that receiving a full accreditation from the JCAHO is still the gold standard for a hospital’s quality of care.

The JCAHO is continuously updating their standards and issues a new standards manual each year. While the actual changes made each year may be minimal, they often occur as a result of information sent to the JCAHO by hospitals regarding medical errors under the so-called Sentinel Event standard. For our purposes, it is important to use the correct annual edition of the standards in evaluating a medical malpractice case.

The accreditation process focuses on following randomly selected actual patients care from admission to discharge. The strength of this process is that it does look at actual care processes rather than the former process which only looked at whether the hospital complied with the standards on paper. Its weakness is obviously that most patient care is performed correctly and most patients receive high quality care, while being accredited does not mean that every standard was complied with and some important processes may not be evaluated in the every three year survey process. Hence, a fully accredited hospital may have some issues and problems that the accreditation process does not uncover.

With this background in mind, I recommend using the standards to evaluate the hospital’s corporate responsibilities in delivering care to their patients. The standards include such things as the board’s responsibility to lead the hospital, the administrator’s job requirements, how physician credentialing should be accomplished and the overall delineation of the way patient care should be delivered. The standards require the hospital to have a number of policies and procedures in place and further require that they be actually followed uniformly for all patients regardless of their ability to pay or the type of insurance they have. While it is important to note that these policies must exist, the JCAHO does not typically prescribe how the hospital should accomplish the required activities. Each hospital has a great deal of latitude in how they do things and this often provides us with key insights in how seriously the hospital takes this process. For example, the hospital should look at all key policies annually and update them as needed based on their own experience as well as industry information regarding changing processes. Hospitals often do not do this on a regular basis and it is not unusual for me to see policies that have not really been changed for many years.

In today’s complex health care delivery environment it is crucial for a hospital to understand that its corporate responsibilities must be taken seriously and I often counsel hospitals on how to improve their risk management processes. Conversely, in my work with patient’s counsel I look for evidence that any deviation in implementing these corporate responsibilities caused the hospital to bear some responsibility for a medical malpractice event. In my opinion, this evaluation should take place in every case in order to determine if the hospital has essentially participated in the process that caused the case to occur.

This medical malpractice article was written by an expert witness working with American Medical Experts, LLC (AME). AME is the nation’s leading source of medical experts for case review and testimony; AME also offers the lowest flat rate fees on Complete Case Reviews ($695) and Expert Witness Reports ($995). For more information, call 888-678-EXPERTS (888-678-3973) or visit AmericanMedicalExperts.com.

Narcotic Overdose - Medical Malpractice

Narcotic injections are frequently used in hospitals to control pain, sometimes augmented with the use of tranquilizing medications. However, tranquilizing drugs in combination with narcotics will increase the risk for respiratory depression.

That is, they chemically narcotize the breathing centers in the base of the brain (the medulla) and can stop the patient's breathing. If this is not recognized immediately, death ensues.

Elderly patients and children are more susceptible to the respiratory depression side effects of narcotics and tranquilizers.

The frequency of injection should be not closer together than every three hours, and the dosage and cumulative effect of combinations of medications must be taken into consideration by both the ordering physician and the treating nurses, both of whom have independent duties to protect patients.

This medical malpractice article was written by an expert witness working with American Medical Experts, LLC (AME). AME is the nation’s leading source of medical experts for case review and testimony; AME also offers the lowest flat rate fees on Complete Case Reviews ($695) and Expert Witness Reports ($995). For more information, call 888-678-EXPERTS (888-678-3973) or visit AmericanMedicalExperts.com.

Missed Diagnosis of Appendicitis

The diagnosis for appendicitis is fairly straightforward. The patient usually presents with mid-abdominal cramping pain that localizes, within 12 to 24 hours to the right lower quadrant of the abdomen.

A rectal examination usually documents pain in the right lower side. A pelvic examination helps to rule out an infection of the Fallopian tubes (usually from gonorrhea). The temperature is usually about 100 degrees, and the white blood count is slightly elevated.

When in doubt, surgery is warranted. As hours pass, there is a risk of the infected appendix rupturing (perforating), resulting in an intra-abdominal abscess and risk of death. In children, the passage from the onset of appendicitis to perforation is usually less than 24 hours, and their risk of wide spread intra-abdominal infection is much greater than in an adult.

Time is essential to saving lives; the earlier appendicitis is detected, the better the patient will be. Doctors must be vigilant in detecting these symptoms and acting appropriately in order to avoid negligence.

This medical malpractice article was written by an expert witness working with American Medical Experts, LLC (AME). AME is the nation’s leading source of medical experts for case review and testimony; AME also offers the lowest flat rate fees on Complete Case Reviews ($695) and Expert Witness Reports ($995). For more information, call 888-678-EXPERTS (888-678-3973) or visit AmericanMedicalExperts.com.

Thoracic Outlet Syndrome

Thoracic outlet syndrome is a condition where the nerves to the arm, the brachial plexus, are squashed between the collar bone (clavicle) and the first rib beneath. When the patient repetitively raises their arms up (as in hanging sheetrock on the ceiling) they can have numbness and nerve difficulties with their arms. However, these symptoms do not necessarily indicate that an operation is needed.

They can be instructed to change their job, and physical therapy can be effective. If the condition is severe it must be confirmed by doing what is called an Adson maneuver. This involves raising your arm up in the air and all the way back to where the pulse to your wrist is cut off.

The artery goes through the same area the nerves are going through, and will be compressed by the squeezing action of those two bones. If this test is positive it does not necessarily mean that surgery is needed; many people can have a positive test without any symptoms.

Neurologically the area is evaluated with electrical studies, such as an electromyogram and nerve conduction studies, and, if you document an area of damage, then the arteriogram x-ray should also be done.

After all conservative therapy fails and the cause is documented, the operation can be performed. It's done through the axilla (the armpit region) and there is a risk of nerve injury. The risk depends upon who is operating. The risk of causing nerve damage to that brachial plexus from carelessness can be from five to fifty percent. That's one issue of negligence, as well as any departures from the standards of care, if proper informed consent was not obtained, if physical therapy to avoid surgery was not done, alternatives were not discussed, and unnecessary surgery was performed.

This medical malpractice article was written by an expert witness working with American Medical Experts, LLC (AME). AME is the nation’s leading source of medical experts for case review and testimony; AME also offers the lowest flat rate fees on Complete Case Reviews ($695) and Expert Witness Reports ($995). For more information, call 888-678-EXPERTS (888-678-3973) or visit AmericanMedicalExperts.com.

Prescription Medication Side Effects

Every year 2 million Americans have side effects and complications from prescription medications. And 100,000 die.

Every prescription medication must have a Food and Drug Administration (FDA) approved “drug insert”. This must list the indications, contraindications, side effects, as well as incompatibilities with other medications. This is reprinted every year in the book: Physicians Desk Reference (PDR).

Every patient must be informed of the major side effects and questioned as to any other medications – prescription or over-the-counter (OTC) they may be taking, to reduce all their risks.

One consideration in your drug side effect cases is whether the prescribed medication was actually needed, whether the dose was correct, and whether the least toxic drug was prescribed.

This medical malpractice article was written by an expert witness working with American Medical Experts, LLC (AME). AME is the nation’s leading source of medical experts for case review and testimony; AME also offers the lowest flat rate fees on Complete Case Reviews ($695) and Expert Witness Reports ($995). For more information, call 888-678-EXPERTS (888-678-3973) or visit AmericanMedicalExperts.com.

Missed Diagnosis of Pre-Eclampsia

If the patient starts out her pregnancy with 130/70 blood pressure and the 70 changes to 80, it must be looked at, not necessarily treated, but looked at. If the 80 goes up to 85, then you have to be concerned about the possibility of early pre-eclampsia, a high blood pressure condition in pregnancy which can cause damage to the mother and the baby. When there is high blood pressure in the mother, blood flow to the placenta, which nourishes the baby, is impaired and there is a higher risk of the placenta separating from the lining of the uterus (abruptio placenta).

Patients suspected of having possible pre-eclampsia are also given urine tests. Protein appear in the urine abnormally; we call it "spill out".

Actually, the protein leaks through the filtering system of the mother's kidneys into the urine. The mother's kidneys filter her blood to remove her impurities and those she absorbs into her blood from the baby through the placenta. With high blood pressure, the filtering mechanism is damaged.

In pre-eclampsia, protein which is in the blood and which should stay in the blood and not go in the urine will go into the mother's urine where it can be picked up with these simple, inexpensive tests. It's standard to check the urine for protein at every obstetrical visit. If any protein is found and if the level of protein in the urine rises, and/or if the blood pressure is rising, the doctor must be concerned about pre-eclampsia.

Reflexes (knee jerk, ankle, elbow) are tested at each office visit. In pre-eclampsia, these responses become more active (brisker) and are another indicator of potential problems.

If the blood pressure starts rising, the woman must be placed at absolute bedrest (other than going to the bathroom) and a low salt diet prescribed to treat and prevent progression of pre-eclampsia. Often this works. If that doesn't work, then you give the mother tranquilizing medications such as the barbiturate Phenobarbital or a sedative. If that doesn't work, you begin some of the mild antihypertensive agents which reduce blood pressure.

If this office and home treatment for pre-eclampaia is ineffective, the woman must be hospitalized quickly. This is a clinical judgment; however, it can also be poor judgment, which is negligence. If the diastolic pressure starts to rise to 90 or 95, then she must be hospitalized, regardless of the week of pregnancy. She must be kept in a hospital environment, under treatment, so the blood pressure stays down in a range safe enough to protect the mother and baby. Then the mother can carry the baby as close to term as possible; as close to the forty weeks the baby would normally go. If the blood pressure continues to rise however, at that point the obstetrician must intervene to deliver the baby. This can be done either by induction with the hormone-like medication Pitocin which stimulates the uterus to contract down so the mother can deliver the baby vaginally or, if that's not successful, and the blood pressure continues to rise, then by a Caesarean section operation.

The mother is given either general or spinal anesthesia which paralyzes and numbs the abdominal muscles. The abdomen is cut and opened between the umbilicus (the belly button) and the pubic bone. The bladder is separated from the lower third of the uterus. The uterus is opened, the baby taken out and the placenta (afterbirth) removed.

Then everything is sewn back up again. The only definitive treatment for pre-eclampsia is to deliver the baby without delay.

This medical malpractice article was written by an expert witness working with American Medical Experts, LLC (AME). AME is the nation’s leading source of medical experts for case review and testimony; AME also offers the lowest flat rate fees on Complete Case Reviews ($695) and Expert Witness Reports ($995). For more information, call 888-678-EXPERTS (888-678-3973) or visit AmericanMedicalExperts.com.