Medical Malpractice Tips

Deep Vein Thrombosis And Pulmonary Embolism Medical Malpractice Cases:

Deep vein thrombosis (DVT) commonly affects the leg veins (such as the femoral vein or the popliteal vein) or the deep veins of the pelvis. Occasionally the veins of the arm are affected (if spontaneous, this is known as Paget-Schrötter disease). A DVT can occur without symptoms, but in many cases the affected extremity will be painful, swollen, red, warm and the superficial veins may be engorged.

The most serious complication of a DVT is that the clot could dislodge and travel to the lungs, which is called a pulmonary embolism (PE). DVT is a medical emergency; present in the lower extremity there is 3% chance of a PE killing the patient.

Blood clots form in leg veins, break off and travel through the larger veins into the inferior vena cava, through the right atrium (blood receiving chamber of the heart), through the tricuspid valve into the right ventricle where it pumped under force through the pulmonic valve into the pulmonary (lung) artery. There it lodges like a cork blocking unoxygenated blood to that segment of the lung. Often small clots break off from the leg veins over time and then a very large clot which can block the heart/lung circuit causing death.

Post-operatively did the patient have anti-embolism elastic stockings ordered by the Surgeon and put on by the nurse? Were they used for every bed bound patient? Lying in bed causes blood to stagnate in the leg veins. Were the nurses encouraging the patient to exercise their legs in bed, particularly their feet /ankles up and down every hour? This motion caused by their leg muscle contractions, forces blood to move faster through their veins and reduces the risk of clotting.

The elastic bandages compress the superficial veins forcing more blood to flow faster through the deep veins, where the greater risk of clotting occurs.

Also, in high-risk immobile patients the use of an injectable blood thinner (anticoagulant), heparin at 5,000 units, twice a day, also reduces that risk without significantly increasing the risk of bleeding.

With chest pain occurring in such a high-risk patient, the diagnosis of a pulmonary embolism must be considered and ruled out. Was a Spiral CT ordered, Blood gases, ankle pumps, regular blood tests to determine therapeutic status of anti-coagulation done, was there a consult with a pulmonary specialist?

With the diagnosis made, therapeutic doses of heparin (anticoagulant drug) are given to decrease the clotting ability of the blood as measured by the partial thromboplastin time (PTT) test. This drug is usually continued for 5-10 days after the symptoms are gone, and then the patient is converted to the oral anticoagulant Coumadin (warfarin) for 6 months to one year.

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Emergency Room- Medical Malpractice:

The usual problem with emergency medicine is a missed diagnosis and the failure to call in a consultant. A patient with chest pain should have an electrocardiogram. If there is an index of suspicion of heart attack and even if the electrocardiogram is normal, the patient should be admitted to the hospital and observed in the coronary care unit with electrocardiogram monitoring. Under those circumstances, eighty percent of patients who arrive in a hospital with a heart attack leave alive. The major cause of death, in these cases, is an irregular beating action of the heart, an arrhythmia called ventricular fibrillation, which is treatable with drugs and electric shock.

A small percentage of patients will develop a rupture of the heart muscle wall from scar tissue weakening, after a severe heart attack, or total heart failure because the entire heart muscle has been turned to gangrene flesh due to lack of blood flow through a blocked main coronary artery. The controlling muscle struts of the heart valves can be damaged from the effects of the heart attack. Most patients, however, leave the hospital alive if their condition is immediately recognized and properly treated. Heart attack misdiagnosis is not an uncommon emergency room cause of action.

Were the consultants called timely? Did the nurses intervene on their own when they saw problems? Was the patient hooked up to a monitor? Was the patient left alone? Was a proper history taken?

We see the headache question. If the patient has an acute headache and high blood pressure, the blood pressure must be treated and a neurosurgeon called in if there are signs or symptoms of brain damage. One of those emergency conditions is an aneurysm, a weakening of a blood vessel at the base of the brain, supplying blood to the brain. If timely recognized, and if the blood pressure is reduced and anticlotting medication like the drug Amicar (also called epsilon or amino-caproic acid) is given, they can help prevent or limit the degree of hemorrhage into the brain substance. Blood pressure can be reduced rapidly with medications. Emergency surgery can be done. If the patient is stable, surgery can be delayed up to two weeks until the scarring around the blood vessel is thicker, making surgery safer. The decision to operate depends upon which blood vessels are involved and the clinical circumstances. Recognition is the key.

The emergency room doctor must have an index of suspicion, and he must take a proper history. Did this patient have chronic headaches? Was this a severe and new headache, localized differently, which he never had before? High blood pressure or not, either way the patient should be observed. Consultants should be called. The purpose of an emergency room doctor is to treat emergencies, to have a high index of suspicion, to consider all differential diagnoses, and to call in consultants.

Other than skin wounds, hand injuries and deep wounds should never be sutured in the emergency room. A hand surgeon, general surgeon, orthopedic surgeon or plastic surgeon should be called. The patient should be taken to an operating room where the wound is again cleansed thoroughly and the tendons are examined with the patient’s physical movements. The entire area of the tendon should be checked for complete or partial severance. The inside of the cut must be examined to be sure those structures weren't injured, all foreign substances such as dirt and glass were removed, and appropriate x-rays taken. Suturing up the wound and leaving dirt behind, with gas gangrene infection setting in, is usually provable negligence in an emergency room situation, depending upon the circumstances.

Human and animal bite wounds should never be sutured. They are highly contaminated and cannot be totally "sterilized". If a patient had a dirty wound from falling down in their backyard, which the dog or cats use as a bathroom, we never suture that up because the patient can get gas gangrene from the germs that are present. We have to cleanse out the wound thoroughly, give antibiotics, and usually admit the patient to the hospital. Never close the skin primarily, including "old” cuts present for more than eight hours; the risk of infection developing is too great. Depending upon their condition and who is going to see the patient, sometimes they can be sent home. The point is, a consultant should be called and proper hospital care and follow up care given. All follow up instructions must be in writing and given to the patient or to a responsible person who can understand the instructions.

Emergency room doctors recognize and respond to emergency situations; they must call in consultants immediately so that they can triage the patient to the proper person at the right time. Stab wounds, gun shot wounds, that's obvious: he should call someone. In chest wounds, fractured ribs can pierce or collapse a lung. He must get a chest x-ray. Did they perform all the x-ray studies, take all the appropriate blood tests for the condition? Did they take the medical history properly? Did they give instructions for follow up care for head trauma? If the patient has a head injury, but no loss of consciousness, the x-ray is negative, and they are neurologically intact, they can be sent home. The family must be told to awaken the patient every hour. If there is a change in the neurologic condition, and confusion, lethargy, developing paralysis or vomiting occur, they are to bring him back immediately. A CAT scan should be taken at that point. (Perhaps a CAT scan before, depending upon the condition and the nature of the injury.) Follow up instructions are critical in emergency rooms. If they fail to provide these instructions, then they're negligent.

Emergency room doctors also see neck injury patients. With patients in automobile accidents, is there a fractured neck? What difference does it make? Well, if the neck is fractured and the bones are unstable, the spinal cord can be squashed, causing paralysis, paraplegia or quadriplegia. There has to be an index of suspicion. The patient has to be stabilized with the understanding that these conditions may exist until ruled out. The patient is stabilized, protected against himself when they're drunk, and taken to x-ray with supervision, where x-rays of the neck are taken. X-rays of the whole neck should be taken, (not just of the first four cervical vertebrae, but of all seven) to look for a fracture, dislocation, to see stability, and to call a consultant in when necessary. Hospital personnel have a duty to have a high index of suspicion, and to use the tests that are available to them.

Most emergency room doctors today are certified in Emergency Medicine, and every doctor working in an emergency room is held up to that standard of care. The moonlighting eye doctor taking care of a baby is held up to an emergency room standard of care. They must call the appropriate consultants.

Cardiovascular Surgery Malpractice Case

Trasylol/Aprotinin is a drug commonly used during heart surgery; it is known to cause serious complications. These complications include kidney damage, an increased risk of a heart attack, heart failure and stroke.

Trasylol is a drug that has been on the market for 13 years and is used to control bleeding. This drug is used in as many as 1 million heart and bypass surgeries per year.

Trasylol doubles the risk of kidney damage but also increases the risk of heart attack by 48%. Heart failure risk is also increased by 109% and stroke by 181%.

Because it is given intravenously, most people do not even know that they are receiving it. Also, this drug is so bad they stopped clinical trials as complications exceeded 35%.

The New England Journal of Medicine published a study on 4,374 Heart Bypass surgery patients with regard to the use of Trasylol (Aprotinin) “The Risk Associated with Aprotinin in Cardiac Surgery”. Trasylol (Aprotinin) is Bayer's inject-able drug used to prevent excessive blood loss during surgery.

The results of the study published are:

•Use of Trasylol / Aprotinin for heart surgery to control bleeding doubles the risk of kidney damage.

•Resultant kidney damage forces an estimated 10,000 patients onto kidney dialysis each year.

•Risk of heart attack is increased 48 percent with the use of Trasylol / Aprotinin.

•Risk of heart failure is increased 109 percent with the use of Trasylol / Aprotinin.

•Risk of stroke is increased 181 percent with the use of Trasylol / Aprotinin.

FDA Issues Trasylol Warning

The FDA issued a health advisory on February 8, 2006, in which it warned the public of the increased risk of kidney failure, heart attack, and stroke in patients who were given Trasylol and undergo artery bypass graft surgery.

This study pointed out that there are two other generic drugs that are safer and less expensive than Trasylol. While Trasylol costs $1,300 per dose, generic drugs are available more cheaply. Amicar costs $11 per dose and Cyklokapron is $44 per dose.

Neither of these generic drugs was associated with the same adverse reactions that characterize Trasylol / Aprotinin.

Replacing Trasylol / Aprotinin with one of the two safe generic drugs, would:

• Prevent as many as 11,000 kidney dialysis complications per year
• Save approximately 1 billion dollars in kidney dialysis costs per year
• Reduce heart attack and kidney treatment drug costs by at least $250 million per year

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 and how to retain him for your cases:

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.

The expert who contributed this information is available as a Toxicology Expert. Call our office at 888-678-EXPERTS (888-678-3973) or 703-932-7777 to arrange for a free conference call with this expert and to obtain a copy of his CV.

Misdiagnosis of a Heart Attack

A heart attack (myocardial infarction) is the most common cause of death in both men and women.

Failure to timely treat will result in further irreversible heart damage with the consequence of heart failure, or worse: death.

Classical crushing chest pain is most common in men, but not in women (who more commonly experience jaw, back or arm pain, or just fatigue).

Whenever any adult has symptoms of a heart attack, the following test must be performed: an electrocardiogram (EKG), plus blood enzyme test to rule out heart muscle injury (troponin and CPK).

Even if these are initially normal, the patient should be monitored in a hospital for 24 hours, and retested, especially if they have high risk factors: a previous heart attack, high blood pressure, diabetes, high cholesterol (especially if their LDL {“lousy” cholesterol} is greater than 100), and if they have a family history of a heart attack. The failure to do this is a departure from the accepted standards of care.

Whenever a heart attack is diagnosed, the best treatment is to use blood clot dissolving medication (tPA: tissue plasminogen activator) within 4 hours to reopen the blocked coronary artery before irreversible heart muscle damage (necrosis: gangrene) occurs.

Furthermore, continuous EKG monitoring will allow immediate treatment of any irregular heart rhythm (arrhythmias) before they cause ventricular fibrillation (just twitching of the heart muscle, without any blood pressure being created). Electrical defibrillation (electric shock to the heart) when immediately performed can often restart the heart, saving the patient’s life and brain before irreversible damage results.

If the patient sustained a heart attack and was negligently misdiagnosed, but did not die, the psychological damage can be extensive: heart muscle damage with some degree of heart failure: decreased cardiac pumping efficiency measured by a lower ejection fraction, plus higher risk for a fatal heart attack, and greater need for invasive procedures: angioplasty or coronary artery bypass graft (CABG), with their risks and expenses.

Air Embolism 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.

Nursing Recommended References

J.C.A.H. Nursing Service Standards. The Joint Commission on
Accreditation of Hospitals. Customer Service,
875 N. Michigan Avenue, Chicago, IL.

Lippincott Manual 0f Nursing Practice
J.B. Lippincott Company, Philadelphia, PA.

Drugs and Nursing Implications, Govoni and Hayes.
Appleton-Century-Crofts, Norwalk, CT.

Pharmacology Recommended References

AHA Drug Evaluations, American Medical Association,
Chicago, IL.

Drug Information, American Hospital Formulary Service,
American Society of Hospital Pharmacists, Bethesda, MD.

The Pharmacological Basis of Therapeutics, Louis S.
Goodman, M.D., Alfred Gilman, Ph.D., Editors.
MacMillan Publishing Company, New York.

The Physicians' Desk Reference, Medical Economics Company,
Inc., Oradell, N.J

The Role of Joint Commission on Accreditation of Healthcare Organizations Standards in Medical Malpractice 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.

Anesthesiology case - Medical Malpractice

After any major chest or abdominal surgery, the patient has pain, may not be able to cough well, and may develop pneunonia. The doctor has to be sure that the patient is breathing properly, has physical therapy for the chest problems, or suction of the throat and trachea if needed. A tracheostomy, which is a cut in the windpipe, for direct and frequent suctioning of chronic lung patients, should be performed when indicated. If their lungs are failing, they should be given adequate oxygen by putting them on a respirator (ventilator). All these are parameters which have to be reviewed with regard to postoperative care of patients.

In anesthesia, the critical thing is management of the airway. Was a tube placed into the trachea, (windpipe) properly and immediately and connected to the ventilating machine? Was oxygen given? Was nitrous oxide, a gas anesthetic, switched on instead of oxygen? Was the proper anesthetic gas given? Was the patient given sufficient oxygen? When there is a complication and the patient was not getting oxygen, did the surgeon notice during surgery that the red arterial blood was turning blue? Was the blood changing color? Were the fingernails in a female patient void of nail polish so the pinkness of the oxygen content of the blood could be seen? The doctors have to be able to monitor the patient properly and if there is a complication, to recognize it in a timely manner.

Many complications of anesthesia in an operating room are preventable. If the patient was placed on his side for kidney surgery, for example, the operating table is bent and a "rest" (an elevation) is pushed up to bend the patient by stretching the muscle from the hip to the rib area, or in chest surgery, under the upper chest to stretch the ribs apart, were the patient's nerves protected under the armpit region? Did the patient wind up with paralysis of the arm? Was their spinal cord so flexed that they became paralyzed? Or, were they lying down on their back with their arms overextended up over the head and the brachial plexus, the nerves to the arms, overstretched? It's negligence. Was the elbow protected? Did they get ulnar nerve damage at the "funny bone" area causing a claw hand? Was the elbow crushed against the metal edge of the operating table and not protected properly? It's negligence. Yes, it is res ipsa loquitur, but you need to have an expert testify that it did not happen in your case in the absence of negligence. It's a medical malpractice case needing analysis and testimony on negligence, causation and damages just as every other case.

Proper positioning of the patient in the operating room is the responsibility of the anesthesiologist, nurse, operating room technician, assistant surgeon and surgeon. Never forget that there is an assistant surgeon, often with his or her own insurance policy, who should be sued. Also, do not overlook each of the anesthesiologists (there are several because they take shifts during long anesthetics). Anesthesiologists, the hospital, the surgeon, the assistant surgeon, and all of the corporations associated with these entities, should be defendants.

Infectious Disease – Medical Malpractice case | Infection Case Strategy

The way to handle infection cases is very interesting. If you can show the operation was not indicated, then any complication from that unnecessary operation is a negligent act. Secondly, was the patient at higher risk for the operation? Were prophylactic antibiotics not given prior to, during and after surgery? Was the patient not immediately and properly diagnosed and treated? In most large cities and/or teaching centers, there are specialists who do practically nothing else but consult and treat infections. Were there infections on or in the patient's body at the time of an elective operation? If so, the surgery should have been postponed.

Was the patient placed into a room before or after surgery where infected patients were located? This doesn't always mean there's a higher risk, but it's good jury appeal.

Did the hospital have infectious disease control procedures? All hospitals are required by the Joint Commission on Accreditation of Hospitals to have such procedures. Did they investigate all other infections which were ongoing, to try to find the source of infection to minimize the risk? Was there a miniepidemic of infections at the time that patient was admitted to the hospital? If so, and if it's elective surgery, the patient should not have been operated on. If it was an urgent situation, he should have been put in another hospital. Did he come down with the same infection as the epidemic type? You can subpoena the infectious disease control records, which the Joint Commission on Accreditation of Hospitals requires the hospital keep. What was the source of the infection? The hospital won't give you the names of the patients, but will tell you what germ was present, where the other infected patients were located in the hospital, their diagnoses, and if it was the same as this patient's germ. Did the operating room nurse have an infected throat? Did the surgeon or his assistants have an infection?

Did his patients have a higher infection rate compared to other doctors at the hospital? Was the patient not advised of that? How were these infections investigated (if at all), what were the findings, and what was done to prevent your client's infection?

Infection cases are difficult, so it is imperative that you take a careful approach and notice all of the details. The primary goal should be finding out if the operation was unnecessary. You should also find out if the medical team failed at any of the following: getting proper informed consent, using conservative therapy, minimizing the risk of using prophylactic antibiotics, and investigating the causes of existing infections. Furthermore, doctors are responsible for recognizing infections immediately, getting germ cultures, using intensive antibiotics, opening the wound on time to get good drainage, and removing diseased flesh and implanted artificial materials. Failure to perform any of these essential tasks results in fatal infections. Taking all of the details above into account can help you understand, prove, and win complex infection cases.

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.

Understanding cancer growth (delay in diagnosis) for jury appeal:

Cancer grows in all directions; in three dimensions. When a chest x-ray shows a tumor, the report says “2x4 centimeters”, but that is only the two dimensional “view”. When the pathology report says “2x4 centimeters” or “2x4x3 centimeters” the jury’s mind does not calculate the volume or change in volume over time. Growth is the three dimensional volume change, and is most impressive.

One can often identify by evidence or opinion, the three dimensions of the tumor at its various stages of growth. This can be mathematically calculated into volume:

If a square shape changes from 2x2x2 centimeters to only 3x3x3 centimeters, the volume grows from 8 cubic centimeters to 27 cubic centimeters, more than three times the volume, “not just” 2x2x2 to 3x3x3.

From 2x2x2 to 4x4x4 is eight times the volume (8 cubic centimeters to 64 cubic centimeters). Spheres can also be simply calculated, but the volume of irregular shapes is measured using calculus. Any competent mathematician can perform this computation for you. Never rely on two or three dimensional tumor sizes. Always convert those to volume and volume growth for the correct size and jury appeal.

Cardiology - Medical Malpractice:

Complications are frequent in the cardiac catheterization procedure, in which either a cardiologist or a radiologist performs the arteriogram studies. A plastic tube, is passed through a needle, usually into the groin (femoral) artery, up through the aorta, (the main artery of the abdomen and chest) and into the openings of the two coronary arteries of the heart. The radiologists use the same technique to do the arteriogram studies of the neck (carotid) arteries. As the catheter passes up the aorta, cholesterol deposits and blood clot debris, which are often found in the elderly, can break off. These follow the blood flow and often block the arteries to the legs.

The patient has to be told of that risk, and then the complication has to be followed up. The dislodging of that debris during the study is often unpreventable as it is a rather "blind" manipulative procedure.

If there is a blocked off blood vessel from embolization of this "debris", then a vascular surgeon is called. Plastic tubes called Fogarty embolectomy catheters, skinny tubes with a deflated balloon around the end are pushed through the clot, inflated and pulled back, removing the clots and debris, and often saving a leg if done timely. After eight hours of delay, irreversible changes will occur to the muscles and nerves. Not only will the clot become hard, but the side branches through which the blood would normally flow to the muscles of the leg become solidly blocked off. Even though the main artery is cleared out, these side branches remain blocked off and they won't open up to allow blood flow, so the main artery blood vessel has stagnant flow and will clot off again and again. Timely recognition of the complication and prior informed consent is important.

If the arteriogram operation is done through the arm, into the brachial artery, passing the catheter up to the heart area, that brachial artery can become blocked off (occluded) and if it does, timely operative intervention by a vascular surgeon is required. Complications are sometimes unpreventable, but the failure to treat the complications often is clear medical malpractice.

Cardiologists rarely misinterpret electrocardiograms (EKGs). Most often misinterpretation is on the part of general practitioners and emergency room physicians. The same is true of misdiagnosis or mistreatment of heart failure, which can be confused with asthma. Any new elderly "asthmatic" must have heart failure ruled out, as this can also cause wheezing and shortness of breath. The damages are usually limited to the suffering from the misdiagnosed condition; not to a permanent worsening of the heart muscle condition.

Misdiagnosis of a heart attack is most commonly an emergency room act of negligence and is discussed in that chapter. With the use of recently developed heart drugs (calcium channel blockers) some acute myocardial infarctions can be prevented. Worsening chest pain to the level of incapacitation at rest, increasing frequency, or resistance to Nitroglycerin would require timely institution of these medications. This therapy helps to overcome, to some degree, the “so what” defense to inadequate therapy for severe myocardial ischemia (crescendo angina).

Hernia - Medical Malpractice:

A groin hernia is a protrusion of intestines through the lower abdominal muscular wall. In a male, the testicle (testis) is formed near the kidneys and as the fetus develops the testicle passes through the lower abdominal muscles, down to the scrotum and leaves a potential space through those muscles. Sometimes it drags a little bit of the lining of the abdominal wall (called the peritoneum) with it. There are two kinds of hernias, an indirect and a direct. The congenital hernia is the indirect hernia, caused by the persistence of the protruding peritoneal sac along the passageway of the testis. The direct hernia is caused by the abdominal muscles stretching open from working and aging.

The area that stretches is the site of the greatest weakness around the spermatic cord which passes through these muscles and which brings blood to the testis and sperm from it through the vas deferens.

If there is a real hernia, surgery can be performed. The patient must be warned in advance that there is the chance of the loss of the testicle. If the patient is not informed, that is negligence. The alternative to surgery is the patient wearing a truss; however, this is less effective. There can be some persistent pain and discomfort, which is usually from tying the adjacent nerves in a suture, and is another negligent act.

The testicle is usually lost by sewing the muscles too tightly in the area of repair around the spermatic cord. This will squeeze off the testicle blood supply, causing irreversible damage. Some surgeons have such gross technique they will actually rip the spermatic cord apart! Occasionally postoperative bleeding will occur to such a degree that testicle damage will result. If the bleeding is extensive, exploratory surgery is required to control it, as well as to remove the blood clots (hematomas).

If a recurrent hernia develops it may not have occurred from negligent care. We must review all the records and be told how long the patient refrained from any heavy lifting or hard work. It usually takes three weeks for the hernia repair to properly heal. It is difficult to prove that the loss of a testicle following the repair of a recurrent hernia resulted from negligent care. There can be extensive scar tissue that makes the surgery more hazardous and the defense to that injury is often successful.

There are two nerves in this area, the ilioinguinal and iliohypogastric nerves and either one of them, if they're caught in a stitch, will cause chronic, persistent, severe pain which would require surgery to cut that nerve. If the nerve is cut, this would cause a little insignificant numbness in the upper groin. It can cause severe pain if ligated, which is negligent, and if this pain occurs immediately after surgery, persists and is not diagnosed properly, then it's further negligence causing more pain and suffering.

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.

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

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.

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.

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.

Missed Diagnosis of Appendicitis

Experts Recommended for Maximizing Recovery In Obstetrical Cases:

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.

Infection from Intravenous Fluids Malpractice case

Infection from intravenous fluids are given through a needle or catheter (plastic tube). There 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.

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?

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.

Lung Cancer Misdiagnosis Malpractice case

Lung cancer: does the patient have cancer or is that scar tissue in the lung from tuberculosis or something else? The doctor has a duty to obtain any previous chest x-rays. If this is a "new lump" seen in the lung and the patient had a chest x-ray a year before and five years ago, which showed the same lump, it couldn't be cancer because it hasn't changed.

How was the patient evaluated before surgery? Bronchoscopy, looking into the windpipe, and obtaining sputum specimens for germs and cancer analysis is important. The condition must be properly diagnosed, biopsies performed when possible, the patient told about the risks, and the previous chest x-rays checked.

Very often we see negligence in failing to examine earlier x-rays, whether they were taken for tuberculosis screening, for work physicals, for insurance, for previous hospitalizations, or for any other condition. Have good copies made of all x-rays.

Was the lump seen earlier? Was it misdiagnosed when the cancer cure rate would have been higher? Has it changed? Is it cancer or was it some old scarring, tuberculosis or pleurisy?

Lung cancer is one of the top five diseases in terms of malpractice dollar awards. The typical case alleges misdiagnosis via poor diagnostic methods or mismanagement of diagnostic tests. Delayed diagnosis of lung cancer offers a much poorer prognosis, and therefore any malpractice award is typically large in terms of dollar value.

Obstetrician: Whether or not the defendant is a general practitioner or an obstetrician, the standard of care is that of an obstetrician. That expert will testify to the proper standards of care, which were in effect at the time at that size hospital. He will discuss departures from the proper standard of care, if any, on the part of the doctor, nurses, and the hospital. In addition, many obstetricians would be comfortable in testifying to proximate causation. However, the proximate causation question is best handled by a pediatrician and/or pediatric neurologist.

Pediatrician and/or Pediatric Neurologist: When there is brain damage to the baby, it is important to ascertain the cause. Pre-delivery factors such as infections, hemorrhage within the brain and genetic and other congenital causes unrelated to negligence must be ruled out. The strongest obstetrical malpractice cases are sometime lost because of the "so what" defense.

These experts could also testify to the negligent delivery, with the low Apgar score as the proximate causation of the brain damage (cerebral palsy and/or mental retardation), and could rule out post-delivery causes such as a very low blood sugar, or pediatric or pediatric nursing negligence in failing to adequately suction the baby's throat and maintain adequate oxygenization.

When there are potential multiple insults to the child, they can testify with regard to which ones were substantial contributing factors to the brain damage.

Obstetrical Nurse: The obstetrical nurses are independent personnel who have their own duty to their patient, your client. They are in a position to determine whether or not proper care is being given, and to obtain professional assistance in a timely manner via the chain of command which must be established by every hospital. These nurses are also seeing the patient on an on-going basis and are reviewing the fetal monitor. If there is any evidence of fetal distress or lack of progression of labor, the obstetrician must be notified promptly. The nurses can place the patient on her side to minimize the negative effects of the uterine pressure and contractions on uterine blood flow in the presence of fetal distress, but they also must obtain prompt obstetrical medical assistance.

The nurses will perform sterile vaginal examinations periodically, check the fetal heart rate themselves, and, when an external fetal monitor is being used, position the transducer on the mother's abdomen to get the best recording of the fetal heart beat. They have a duty to record, in their nurses' Labor Room notes, what is happening to the patient and to act promptly upon any "red flags" which may arise.

Radiologist: When there is a question of cephalopelvic disproportion and pelvimetry x-rays were taken, a radiologist can comment upon what the proper interpretation should have been and how that information should be communicated to the attending obstetrician.

Hospital Administrator: He can best express the failures of the hospital to establish protocols and procedures required by the Joint Commission on Accreditation of Hospitals (JCAH) and how those failures caused or increased the risk of injury to the plaintiff. He can also discuss physician credentialing failures, nurse training failures and equipment inspection failures.

Psycho-Neurologist: This expert is a Ph.D. who specializes in sophisticated testing of all parts of the brain to detect and quantify all damages. Such damages include motor skills; intellectual functioning such as basic mathematical, reading, understanding, communicating and reasoning skills; sensory skills of vision, hearing, smell, taste and feel; memory; thought processes; and the patient’s response to any defects. Based on the dysfunction found, causation, permanency and special education needs can also be discussed.

Forensic Psychologist: This expert can administer the objective psychological tests to determine the full extent of emotional damage and emotional dysfunction of the child. They can testify as to what such a damaged child would perceive their injury to be as they age, and how that would affect them further. The psychologist can examine and test the family as well.

Forensic Psychiatrist: This expert will continue the psychiatric evaluation as a physician, and both he and the clinical psychologist will then "cry to the jury", for the anguish of the child and family.

Occupational/Disability Expert: This expert will discuss the physical and mental limitations of the patient from a physician's aspect, and explain how those disabilities would substantially interfere in job performance in the future (and, therefore, limit income) and how they will interfere in normal daily living, thereby increasing the psychological damages. These experts can also discuss the need for remedial and corrective operations, if indicated. The related costs and pain and suffering from such corrective surgery and care can best be expressed to the jury by this type of expert.

Employability Expert: This is a Ph.D. (not a physician) who can discuss what such a patient, if mentally intact, would have been able to earn, based upon a high school education, and normal physical condition in his city and job market versus what limitations are now imposed and based upon the disability as documented by the previously mentioned physician and Ph.D. experts.

Economist: This expert will place the dollars and cents before the jury, based upon loss of income from diminished earning capability, as testified to by the employability expert and disability experts. This, in conjunction with the cost of future medical care as testified to by the pediatrician and occupational medicine/disability experts and other physicians can clarify the economic issues (as established by your state statutes and case law) to the jury.

Deep Vein Thrombosis And Pulmonary Embolism Medical Malpractice Cases:

The elastic bandages compress the superficial veins forcing more blood to flow faster through the deep veins, where the greater risk of clotting occurs.