Obstructed Labor, The Cause of Severe Brain Damage

Once a woman goes into labor, it usually progresses in a steady fashion. The pelvic exam can determine the head of the fetus in relationship to the inside of the bones in the birth canal, the pelvis. There is a bony landmark in the pelvis which will be used as the guide in centimeters, as to whether not the fetal head it is minus or plus centimeters as a guide to gauge the progression of the labor.  If this woman is a primigravida, that is pregnant for the first time, now and having a vaginal delivery, this is called an “untried pelvis.” And if she has a narrow pelvis, the android shape, more male-like, as opposed to the gynecoid shape of the fuller pelvis, then this is a red flag that there may be a problem with the head of the fetus passing through the birth canal.

If there is no progression of labor down the birth canal, centimeter by centimeter, then this is a problem that may require a cesarean section rather quickly. The fetal heart monitor under these circumstances is really not the better way to determine if they will be a problem. If the umbilical cord is compressed, then the oxygenated blood supply from the uterus to the fetus would be impaired and the fetal heart rate would drop dramatically. That requires it immediately Cesarean section. But in this case of the failure of progression of labor, the umbilical cord is not compressed, but the head is repetitively forced against the inside of the solid bone pelvis. Unlike football players wearing a helmet, this fetal skull has no helmet, and its head is forced under great compression pressure, every few minutes, as opposed to an occasional football concussion. This repetitive concussion will cause brain damage. The failure to observe an obstructed delivery is a departure from the accepted standard of care.

Surgical Mesh Complications in Hernia Repairs

A hernia is a weakness in the abdominal musculature, through which the intestines can protrude. For many years, since the late 1800s, surgeons have been repairing this weakness by suturing the layers of the adjacent fibrous flesh together.

However, because of the low but significant failure rate of the original suturing to hold, requiring a repeat hernia operation, which by itself is not a departure from the accepted standards of care, or when an operation was required to repair a very large hernia, surgeons have been using a plastic woven cloth, a mesh. This allows the body’s scar tissue to grow into this material, to serve as an internal girdle, a buttress, to decrease the failure of the surgical repair.

Whenever any foreign material is inserted into the human body, there is an increased risk of infection. The presence of foreign material makes it much more difficult for the body to fight off any infection. Even with the most sterile procedures, there is that very small risk of infection, including from the human body itself, such as from brushing teeth, where germs can enter the bloodstream and “seed out” at that surgical mesh site.

Furthermore, whenever any foreign material enters the human body, there is a small propensity for the body to eliminate it, as if it were a splinter working its way through the skin.

The standard of care requires that the surgeon explain the need for the use of the mesh to lower the failure rate for the hernia repair. And during this discussion, the surgeon also needs to inform the patient of the slight increased risk for infection, as well as the possibility for the foreign substance to work its way out of the body.

Thoracic Outlet Syndrome

Thoracic outlet syndrome is a condition where the nerves in the arm, the brachial plexus, are squashed between the collarbone (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. That doesn’t mean an operation is indicated, however.

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.

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Urology and the Potential for Medical Malpractice

I was invited to write an article about potential medical malpractice situations in Urology. I thought about several areas of urology and what the common denominators were. The two I see most frequently are … failure to diagnose and/or treat appropriately and failure of communication in an understandable and comprehensive manner with the patient and designated second (if appropriate). I have chosen to discuss the failure to diagnose, evaluate and treat hematuria (blood in urine) in an appropriate manner.

Hematuria may occur in an isolated field (no associated symptoms) or associated with urgency, frequency, dysuria, abdominal pain. Fever is variable. Abdominal distention (swelling or bloating) is also variable. Usually, the first physician seen is the PCP who will usually institute treatment for a UTI. He should obtain a urine culture as the minimal workup along with a urinalysis. If this treatment does not work or the bleeding recurs in a short period of time, a referral to a urologist is indicated.

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The Benefits of a Physician Assistant Expert Witness

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.

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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.

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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 a 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.

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Life Care Planner: A Roadmap For Care

A Life Care Plan is a roadmap for care, describing anticipated medical and non-medical needs, with associated costs, of a person with a catastrophic injury or chronic illness over an estimated lifespan. It is based on standards of practice, comprehensive assessment, collaboration with all medical professionals, and analysis of medical records.

Life Care Planner’s help patients who have suffered catastrophic injuries and illnesses, advocate for them and plan out their care. Nurse Life Care Planners work with a patient’s family, insurance company, attorneys, and others to develop a life care plan, determining the future needs, services, and costs of care for the patient over their lifetime. Many Nurse Life Care Planners work independently from the hospital system, acting as a consultant for businesses, families, or courts of law. Because of life care plans, patients’ caregivers know how often they need to schedule appointments, what to expect in terms of rehabilitation, and what the course of medical care will look like.

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Dog Bite Cases & Childhood PTSD

Dog bites can have very serious repercussions in a child’s life and can change their behavior, functioning, personality, self-esteem, impact a child’s educational progress as well as anxiety and years of counseling. For example, this patient is a seven-year-old white female, experienced a severe dog bite on her face. This was the result of a neighbor not keeping his Pit Bull on a leash. The neighbor was subsequently arrested and charged with Child Endangerment. The patient is now left with some significant scarring on her face. She is teased about this at school and her self-esteem has become quite low. Prior to the dog bite, she was a normal little girl and did well in all aspects of her life. Since the dog bite, she has had a deterioration in functioning.

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Breast Implant Surgery Gone Wrong

Breast surgery that utilizes breast implants is very common and includes surgery for both cosmetic and reconstructive diagnoses.  As in all procedures, informed consent is a very important component in preparing the patient for surgery.  Lack of sufficient informed consent before a procedure that uses breast implants can reach the level of malpractice.

A patient consulted with her Plastic Surgeon about having a breast augmentation.  As a 4’ 11” person who weighed 96 lbs., she told the doctor that she currently wore a 32 a bra and wanted to be augmented so she could wear a 36 D bra.  She was very concerned about the possibility of implant rupture; she did not want to face the extra expense this would cost her.  Her doctor assured her that he could surgically place implants that would give her the size she wanted and told her that, although he had never seen a patient with ruptured implants, if the implants did rupture, her insurance company would cover those costs.   She had the surgery performed but was very unhappy because her bra size was only 34B, much smaller than her desired size.  Also, 5 years later one of the implants ruptured, requiring removal and replacement.  Her insurance company did not cover the costs of that surgery and she had to pay for this surgery out of pocket.

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