Legal Nurse Consulting –
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AMERICAN COLLEGE OF SURGEONS │Standard of Care Guidelines for Concurrent Overlapping Surgeries

Posted by Kathleen on May 22nd, 2018


boat1The Operation—Intraoperative Responsibility of the Primary Surgeon

General Statement

The primary attending surgeon is personally responsible for the patient’s welfare throughout the operation. In general, the patient’s primary attending surgeon should be in the operating suite or should be immediately available for the entire surgical procedure. There are instances consistent with good patient care that are valid exceptions. However, when the primary attending surgeon is not present or immediately available, another attending surgeon should be assigned to be “immediately available.”

The definitions at the end of this Statement provide essential clarification.

Concurrent or Simultaneous Operations

Concurrent or simultaneous operations occur when the critical or key components of the procedures for which the primary attending surgeon is responsible are occurring all or in part at the same time. The critical or key components of an operation are determined by the primary attending surgeon. A primary attending surgeon’s involvement in concurrent or simultaneous surgeries on two different patients in two different rooms is inappropriate.

Overlapping Operations

Overlap of two distinct operations by the primary attending surgeon occurs in two general circumstances.

The first and most common scenario is when the key or critical elements of the first operation have been completed, and there is no reasonable expectation that the primary attending surgeon will need to return to that operation. In this circumstance, a second operation is started in another operating room while a qualified practitioner performs noncritical components of the first operation—for example, wound closure—allowing the primary surgeon to initiate the second operation. In this situation, a qualified practitioner must be physically present in the operating room of the first operation.

The second and less common scenario is when the key or critical elements of the first operation have been completed and the primary attending surgeon is performing key or critical portions of a second operation in another room. In this scenario, the primary attending surgeon must assign immediate availability in the first operating room to another attending surgeon.

The patient needs to be informed in either of these circumstances. The performance of overlapping procedures should not negatively affect the seamless and timely flow of either procedure.

Multidisciplinary Operations

Contemporary surgical care often involves a multidisciplinary team of surgeons. During such operations, it is appropriate for surgeons to be present only during the part of the operation that requires their surgical expertise. However, an attending surgeon must be immediately available for the entire operation.

Delegation to Qualified Practitioners

The surgeon may delegate part of the operation to qualified practitioners including but not limited to residents, fellows, anesthesiologists, nurses, physician assistants, nurse practitioners, surgical assistants, or another attending under his or her personal direction. However, the primary attending surgeon’s personal responsibility cannot be delegated. The surgeon must be an active participant throughout the key or critical components of the operation. The overriding goal is the assurance of patient safety.

Procedure-Related Tasks

A primary attending surgeon may have to leave the operating room for a procedure-related task, such as review of pertinent pathology (“frozen section”) and diagnostic imaging, discussion with the patient’s family, and breaks during long procedures. The surgeon must be immediately available for recall during such absences.

Unanticipated Circumstances

Unanticipated circumstances may arise during procedures that require the surgeon to leave the operating room before completion of the critical portion of the operation. In this situation, a backup attending surgeon must be identified and available to come to the operating room promptly.

Circumstances in this category might include sudden illness or injury to the surgeon, a life-threatening emergency elsewhere in the operating suite or contiguous hospital building, or an emergency in the surgeon’s family.

If more than one emergency occurs simultaneously, the attending surgeon may oversee more than one operation until additional attending surgeons are available.

Surgeon-Patient Communication

The surgical team involved in an operation is dependent on the type of facility where the operation is performed and on the complexity of the surgical procedure. At a freestanding outpatient surgery center, many procedures are performed solely by the primary attending surgeon with no assistant. In contrast, a complex procedure at an academic medical center may involve multiple qualified medical providers in addition to the primary attending surgeon. As part of the preoperative discussion, patients should be informed of the different types of qualified health care professionals who will participate in their operation (assistant attending surgeon, fellows, residents and interns, physician assistants, nurse practitioners, and so forth) and their respective role should be explained. If an urgent or emergent situation arises that requires the surgeon to leave the operating room unexpectedly, the patient should be informed subsequently.

 

DEFINITIONS

In an effort to provide some standardization of nomenclature, the following definitions are provided:

Backup surgeon/surgical attending

The qualified surgical attending who has been designated to provide immediately available coverage for an operation, during a period when the primary surgeon might be unable to fill this role.

Concurrent or simultaneous operations

Surgical procedures when the critical or key components of the procedures for which the primary attending surgeon is responsible are occurring all or in part at the same time.

“Critical” or “key” portions of an operation

The “critical” or “key” portions of an operation are those stages when essential technical expertise and surgical judgment are necessary to achieve an optimal patient outcome. The critical or key portions of an operation are determined by the primary attending surgeon.

Immediately available

Reachable through a paging system or other electronic means, and able to return immediately to the operating room. This term should be defined more completely by the local institution.

Informed consent

Described in American College of Surgeons Statements on Principles.

Multidisciplinary operations

An example of a multidisciplinary operation is a procedure in which a surgeon of one specialty provides the exposure required by a second surgeon who performs the main surgical intervention (such as a general or thoracic surgeon providing exposure for a neurosurgeon or orthopaedist to operate on the spine). Another example would be an operation that requires the involvement of two or more surgeons of different specialties (such as chest wall or head and neck resection followed by plastic surgical reconstruction, face or hand transplantation, and repair of complex craniofacial defects).

“Overlapping or sequenced” operations for surgeons

The practice of the primary surgeon initiating and participating in another operation when he or she has completed the critical portions of the first procedure and is no longer an essential participant in the final phase of the first operation. These are by definition surgical procedures where key or critical portions of the procedure are occurring at different times.

Physically present

Located in the same room as the patient.

Primary attending surgeon

Considered the surgical attending of record or the principal surgeon involved in a specific operation. In addition to his or her technical and clinical responsibilities, the primary surgeon is responsible for the orchestration and progress of a procedure.

Qualified practitioner

Any licensed practitioner with sufficient training to conduct a delegated portion of a procedure without the need for more experienced supervision and who is approved by the hospital for these operative or patient care responsibilities.

 

Kathleen A. Mary, RNC, Legal Nurse Consultant Certified is an honored medical expert and lifetime clinical scholar valued immeasurably by her plaintiff and defense attorney-clients as a time/cost-efficient asset to medical malpractice, personal injury and product liability claims. Kathleen provides flawless investigative navigation of meritorious complexities, meticulous comprehensive medical record reviews, locates trusted preeminent experts, is a recognized medical researcher and lifetime standard of care clinical consultant. For over 25 years, 100% of Kathleen’s cases (hundreds) have been positively settled without trial. Please contact Kathleen for your next medical-legal case.  

 

 

Autopsies Help Establish Merit in a Medical Malpractice Case

Posted by Kathleen on May 12th, 2018


boat1When someone has died from medical malpractice, an autopsy can provide the foundation for a successful case.

Benefits of an Autopsy in a Medical Malpractice Case

  1. An autopsy verifies the cause of death

Opinions from the most respected experts become much more convincing when accompanied by an autopsy. The majority of autopsies are conducted by pathologists with extensive training in determining cause of death. The pathologist will examine every detail of the body to determine what happened, and will note all findings in a report that can be invaluable in a wrongful death case. At the end of the autopsy, you will usually have a clear idea of what caused the death. If it was due to the actions or inaction of a medical practitioner, you will most likely know it.

  1. An autopsy is superior to a death certificate

A death certificate lists the cause of death, but often the cause listed – while accurate – will not be very useful for a lawsuit. For instance, many death certificates list “cardiopulmonary arrest” as the cause of death. To the layman the term might seem quite specific, but in reality all it tells you is that the person’s heart stopped beating. When the heart stops a person dies. While the listed cause of death might be completely accurate, it will usually not give enough information to build a case on.

  1. An autopsy provides backup if an expert changes his/her mind

An attorney will use expert witnesses to help support his or her argument. One or more expert witnesses can make all the difference in winning a case – but unfortunately such witnesses can also change their minds. One day the attorney may have everything in order, and the next you may find that the expert is no longer convinced.

An autopsy report does not change from one day to the next. You can depend on it, even if an expert decides that medical malpractice was unlikely.

  1. An autopsy is often necessary to win a case

State law may not require an autopsy in a wrongful death case. However, many times you will need an autopsy to fully convince the court of medical malpractice. An autopsy may be key to winning the case. If nothing else, it will improve your positioning. The more clearly you can present evidence of medical malpractice, the more likely the court will decide in your favor.

An autopsy makes an attorney’s job easier

Even if an autopsy is not absolutely required to win a medical malpractice case, it will certainly make it easier to do so. Proving medical malpractice is often challenging for even the best attorneys. Courts are not eager to hold a doctor or medical care provider responsible for someone’s death if they can help it. Because the plaintiff attorney faces such an uphill battle, it is important to seize every opportunity to make your case stronger. An autopsy is a straightforward way of demonstrating what really happened, in a form that the court can easily understand and appreciate.

Helping You Convince the Court

If someone has died and medical malpractice has played a part, a wrongful death lawsuit is the best way to hold those responsible accountable. Gathering evidence of what occurred is a necessity, and obtaining an autopsy should be a part of your efforts. An autopsy may make all the difference in case outcome.

 

Kathleen A. Mary, RNC, Legal Nurse Consultant Certified is an honored medical expert and lifetime clinical scholar valued immeasurably by her plaintiff and defense attorney-clients as a time/cost-efficient asset to medical malpractice, personal injury and product liability claims. Kathleen provides flawless investigative navigation of meritorious complexities, meticulous comprehensive medical record reviews, locates trusted preeminent experts, is a recognized medical researcher and lifetime standard of care clinical consultant. For over 25 years, 100% of Kathleen’s cases (hundreds) have been positively settled without trial. Please contact Kathleen for your next medical-legal case.  

 

 

 

WRONG SITE SURGERY OCCURS FREQUENTLY and LEADS to MEDICAL MALPRACTICE CLAIMS: wrong body part, wrong patient, wrong surgical procedure

Posted by Kathleen on March 14th, 2018


boat1Wrong site surgery takes place when a surgeon operates on the wrong part of a patient’s body, performs the wrong procedure, or performs on the wrong person. Despite standard of care protocols to prevent it, wrong site surgery happens frequently. For example, a doctor may perform a hip replacement when a kne­e replacement was required, or a left foot amputation rather than the right. Wrong site surgery leads to medical malpractice claims against the surgeon and possibly against the hospital where the surgery took place.

According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 76 percent of wrong site surgeries were surgeries performed on the wrong body part. The other 24 percent were split between operations using the wrong procedure and operations on the wrong person. Researchers from Johns Hopkins found that physicians throughout the United States may operate on the wrong body part as often as 20 times each week.

When a surgeon operates on the wrong body part, the clinical consequences can vary. Consider the following – A surgeon was supposed to remove a patient’s diseased left kidney but ends up removing the healthy right kidney. In such a scenario, the patient would be left without kidney function, and the consequences would be devastating. In less life-threatening situations, a patient will still need an additional surgery to correct the wrong site error. Additional procedures or treatment may also be needed to correct any new problems created by the surgeon’s mistake.

In most states, an injured patient will have a medical malpractice claim if the surgical error was the direct cause of the patient’s harm. Medical malpractice takes place when a doctor fails to use the level of care that another doctor in the same specialty would have used in the same situation, causing harm to the patient. To win in a medical malpractice claim, the patient must establish that the doctor owed the patient a duty of care, the doctor breached their duty of care to the patient by deviating from the standard of care that has been accepted as appropriate in the doctor’s area of practice, and the doctor’s breach was the direct cause of the patient’s resulting injuries.

A plaintiff attorney in a medical malpractice case may be able to recover a variety of damages including medical expenses, rehabilitation costs, lost income and benefits, pain and suffering, emotional distress, and disability. The compensation can come through a settlement or through a jury award.

Kathleen A. Mary, RNC, Legal Nurse Consultant Certified is an honored medical expert and lifetime clinical scholar valued immeasurably by her plaintiff and defense attorney-clients as a time/cost-efficient asset to medical malpractice, personal injury and product liability claims. Kathleen provides flawless investigative navigation of meritorious complexities, meticulous comprehensive medical record reviews, locates trusted preeminent experts, is a recognized medical researcher and lifetime standard of care clinical consultant. For over 25 years, 100% of Kathleen’s cases (hundreds) have been positively settled without trial. Please contact Kathleen for your next medical-legal case.  

 

New American College of Cardiology and American Heart Association High Blood Pressure Guidelines Lower Definition of Hypertension

Posted by Kathleen on December 3rd, 2017


boat1High blood pressure should be treated earlier with lifestyle changes and in some patients with medication – at 130/80 mm Hg rather than 140/90 – based on new American College of Cardiology (ACC) and American Heart Association (AHA) guidelines for the detection, prevention, management and treatment of high blood pressure.

The new standard of care guidelines – the first comprehensive set since 2003 – lower the definition of high blood pressure to account for complications that can occur at lower numbers and to allow for earlier intervention. The new definition will result in nearly half of the U.S. adult population (46 percent) having high blood pressure, with the greatest impact expected among younger people. Additionally, the prevalence of high blood pressure is expected to triple among men under age 45, and double among women under 45, the guideline authors note. However, only a small increase is expected in the number of adults requiring antihypertensive medication.

Blood pressure categories in the new guideline are:

  • Normal: Less than 120/80 mm Hg;
  • Elevated: Systolic between 120-129 and diastolic less than 80;
  • Stage 1: Systolic between 130-139 or diastolic between 80-89;
  • Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg;
  • Hypertensive crisis: Systolic over 180 and/or diastolic over 120, with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage.

The guidelines eliminate the category of prehypertension, categorizing patients as having either Elevated (120-129 and less than 80) or Stage I hypertension (130-139 or 80-89). While previous guidelines classified 140/90 mm Hg as Stage 1 hypertension, this level is classified as Stage 2 hypertension under the new guidelines. In addition, the guidelines stress the importance of using proper technique to measure blood pressure; recommend use of home blood pressure monitoring using validated devices; and highlight the value of appropriate training of health care providers to reveal “white-coat hypertension.” Other changes include:

  • Only prescribing medication for Stage I hypertension if a patient has already had a cardiovascular event such as a heart attack or stroke, or is at high risk of heart attack or stroke based on age, the presence of diabetes mellitus, chronic kidney disease or calculation of atherosclerotic risk (using the same risk calculator used in evaluating high cholesterol).
  • Recognizing that many people will need two or more types of medications to control their blood pressure, and that people may take their pills more consistently if multiple medications are combined into a single pill.
  • Identifying socioeconomic status and psychosocial stress as risk factors for high blood pressure that should be considered in a patient’s plan of care.

The guidelines were published in the Journal of the American College of Cardiology and Hypertension. For a wide array of ACC-developed tools, resources and commentary for both clinicians and patients, visit the ACC’s High Blood Pressure Guidelines Hub.

Read the full article here: http://www.acc.org/latest-in-cardiology/articles/2017/11/08/11/47/mon-5pm-bp-guideline-aha-2017

 

Kathleen A. Mary, RNC, LNCC, Legal Nurse Consultant Certified is an honored medical expert and lifetime clinical scholar valued immeasurably by her plaintiff and defense attorney-clients as a time/cost-efficient asset to medical malpractice, personal injury and product liability claims. Kathleen provides flawless investigative navigation of meritorious complexities, meticulous comprehensive medical record reviews, locates trusted preeminent experts, is a recognized medical researcher and lifetime standard of care clinical consultant. For over 25 years, 100% of Kathleen’s cases (hundreds) have been positively settled without trial. Please contact Kathleen for your next medical-legal case.  

 

 

EMERGENCY ROOM MEDICAL MALPRACTICE │ What goes wrong and why

Posted by Kathleen on November 12th, 2017


boat1About four of every 100,000 Emergency Department (ED) visits result in an allegation of medical malpractice. The analysis below of 1,300 medical malpractice cases involving emergency care, provides insight into what is driving these claims. Because their care is episodic and fragmented, ED patients present multiple care and management challenges, especially in the diagnostic process. The following summarizes what goes wrong and why in a busy ED:

▪ 47% of ED cases allege a failure to diagnose

▪ 39% of ED cases alleging missed diagnosis cite a judgment error related to ordering a test or image

▪ 41% of diagnosis-related ED cases involve inadequate assessment leading to premature erroneous discharge

▪ Community hospital-based physicians and nurses are named twice as frequently in ED medical malpractice cases as are physicians and nurses in academic medical centers

 

Kathleen A. Mary, RNC, LNCC, Legal Nurse Consultant Certified is an honored medical expert and lifetime clinical scholar valued immeasurably by her plaintiff and defense attorney-clients as a time/cost-efficient asset to medical malpractice, personal injury and product liability claims. Kathleen provides flawless investigative navigation of meritorious complexities, meticulous comprehensive medical record reviews, locates trusted preeminent experts, is a recognized medical researcher and lifetime standard of care clinical consultant. For over 25 years, 100% of Kathleen’s cases (hundreds) have been positively settled without trial. Please contact Kathleen for your next medical-legal case.  

 

 

 

 

INFORMED CONSENT │ PHYSICIAN’S DUTY & MEDICAL MALPRACTICE

Posted by Kathleen on November 6th, 2017


boat1In non-emergency situations, medical professionals are required by law to obtain a mentally competent patient’s informed consent for a particular course of treatment. The idea of informed consent is to give patients a meaningful opportunity to be informed about their own health care decisions.

It is a physician’s duty to inform a patient of all potential benefits, risks and alternatives associated with the proposed procedure or course of treatment. This law is intended to give the patient all the information that is required to make an intelligent and informed decision about the treatment. It is important to note that a health care provider does not have to detail every possible risk associated with the treatment. Instead, the scope of disclosure is defined by what a hypothetical reasonable person would find material or important to the decision. A material risk is one which a physician knows or ought to know would be significant to a reasonable person in the patient’s position in deciding whether or not to submit to a particular medical treatment or procedure.

If a medical professional performs a procedure or treatment without first obtaining the patient’s informed consent and the patient is injured as a result, the medical professional may be liable for medical malpractice. Medical malpractice claims are rooted in the theory of negligence, which is a failure to exercise reasonable care that causes harm to a patient. Causation is needed to establish negligence. The relevant question in an informed consent case is: Would the patient have consented to the surgery if he or she had been fully aware of the risks?

If a patient signs an informed consent form stating that the physician explained all of the risks associated with medical treatment, it may still be possible to take legal action against that physician. The form would need to be assessed to determine whether it was sufficient.

 

Kathleen A. Mary, RNC, Legal Nurse Consultant Certified is an honored medical expert and lifetime clinical scholar valued immeasurably by her plaintiff and defense attorney-clients as a time/cost-efficient asset to medical malpractice, personal injury and product liability claims. Kathleen provides flawless investigative navigation of meritorious complexities, meticulous comprehensive medical record reviews, locates trusted preeminent experts, is a recognized medical researcher and lifetime standard of care clinical consultant. For over 25 years, 100% of Kathleen’s cases (hundreds) have been positively settled without trial. Please contact Kathleen for your next medical-legal case.  

 

 

MEDICOLEGAL PITFALLS OF LAPAROSCOPY – Informed Consent, Risks, Intraoperative Errors, Vascular & Organ Injuries, Postoperative Complications

Posted by Kathleen on October 26th, 2017


boat1There has been amazing growth in the actual performance and acceptance of laparoscopy in surgery. As with all surgical treatments, problems may appear, nevertheless, laparoscopy isn’t any exclusion. Surgeons that perform laparoscopy should not only be experienced within the technique in order to avoid as well as handle complications, however they also should completely preoperatively inform patients of the associated risks involved to produce realistic expectations and possibly avert statements of medical malpractice should injury occur.

PREOPERATIVE EVALUATION AND GUIDANCE

It behooves the surgeon just starting a laparoscopic plan to carefully choose patients and cases with regard to reasons associated with individual safety, operating room period, as well as confidence. At the start of the learning curve, doctors may encounter problems when they are not assisted or even proctored through individuals with more laparoscopic experience. Inside a medical malpractice situation, plaintiffs will ask accused doctors what percentage of a particular type of procedure they’ve performed in order to infer lack of experience.

Patients need to understand that minimally invasive is not associated with minimum risk associated with complications. A good guideline: When the patient is at risk to have an open procedure, guidelines suggest he is not a candidate for a laparoscopic one either.

Informed consent for all laparoscopic procedures must include specific mention of the potential dangers as well as complications, such as problems for vasculature, intestinal, bladder, and vital organs, as well as the need to convert to an open procedure if necessary.

PLACEMENT AND POSITIONING

Perhaps within no other laparoscopic procedure would be the placement, padding, and start from the process essential and so possibly tangled up with problems as in laparoscopy. Bone and joint and nerve-related injuries associated with patient positioning are preventable and difficult to defend. It is the surgeon’s responsibility to correctly place as well as pad the patient in order to avoid injury.

Although there are few absolute advisable limitations to laparoscopy, a good assessment of the patient’s relative risks and dialogue associated with family member contraindications are warranted. Earlier abdominal operations and adhesions increase the risk of complications.

ENTRY-RELATED COMPLICATIONS

Entry-related injuries have the effect of a significant proportion of laparoscopy-related complications resulting in claims. There continues to be substantial variation within the entry methods used in medical technique. The Veress needle as well as the first trocar can injure virtually any blood vessel, hollowed out viscera, and vital organs.

Decompression of the abdomen as well as the bladder are important to avoid entry injury.  Failure to appropriately decompress may cause carbon dioxide embolus that is potentially life-threatening; if it occurs, by standard of care, the surgeon should instantly stop the insufflation, decompress the abdomen, place the patient down with right aspect upward, and have the anesthesiologist attempt to aspirate the embolus in the right coronary heart, if possible.

Laparoscopic surgeons must be able to identify as well as respond appropriately whenever something does not look or even feel right. Whenever a patient with earlier abdominal surgical treatment goes through laparoscopy, one should be ready to modify the location associated with Veress needle positioning or even make use of the opening (Hasson) way to prevent trouble. Statements stemming from injuries due to bad common sense and technique may pinpoint the surgical report and deposition of the doctor. Clear, concise, and modern explanations of the operation will help defend your actions whenever there is a claim of medical error. Badly articulated or even inaccurate surgical notes will be utilized as proof of lack of experience or inattentiveness.

Additional factors which plaintiffs’ lawyers will examine regarding entry problems are the stage when the problem first become apparent, and if the surgeon acknowledged this and acted timely and properly. Even though some laparoscopic reviews have claimed that certain trocar or technique is safer compared to another, the truth is that techniques and trocars have been associated with individual injuries. Plaintiffs’ attorneys will invariably blame the defendant’s method or instruments. It is necessary for defendant surgeons to guide their attorney about the various methods and devices and locate experts who agree with and understand their positioning.

DAMAGES

Vascular Injuries can occur earlier and precipitously or even delayed hours postoperatively. Intraoperative blood loss must be managed in a safe and planned fashion. The doctor must recognize and manage bleeding, know when to convert to open surgery, and when to consult general surgery. All types of vascular ligation, staplers, as well as thermal power products, have had failures. Hemostasis is perhaps more essential in laparoscopy compared to open up procedures because of the requirement for a definite visual area in which to operate. Lack of experience can lead some surgeons to convert small injuries to larger ones via bad judgment as well as technique. Plaintiffs have the benefit of hindsight when reviewing problems and injuries.

Major Vessels – The aorta, inferior vena cava, iliac artery, and others can be injured throughout laparoscopic procedures. Injuring these vessels on entry is really a known danger, however will be exploited through plaintiffs as proof of a heavy hand or inexperience. Injury to the actual superior mesenteric artery, celiac axis, or contralateral renal vessels may appear if one confuses the anatomy. During laparoscopic procedures on the renal system, a continuous appreciation for the vasculature as well as ureter is vital as renovascular errors do occur. When encountering anatomy that doesn’t appear correct, cease as well as recheck the images. Confusion is responsible for most mistakes resulting in ligating the wrong vessels within laparoscopy. Digital camera alignment and centering are necessary. Be aware of your own instruments at all times and use all of them very carefully, as it is quite simple to injure any organ or vessel. Inattentiveness accounts for many errors, injuries, and claims associated with laparoscopy.

Bowel and Nerve – Bowel injury subsequent to laparoscopy might have a common or uncommon presentation and disastrous sequelae. Earlier surgical treatment and adhesions increase the probability of intestinal damage with open procedure as well as laparoscopically. Plaintiff positioning focuses on the patient did not give permission for an error caused by doctor- inattention, inexperience, or failure to provide appropriate care. Despite the actual laparoscopy-zoom, injury to large organs do occur.

Vital OrgansThe spleen and pancreas can be injured upon entry or during dissection. Cautious management with dissection and retraction is pivotal to adjacent anatomy. The diaphragm can be injured while dissecting upward. All internal organs and vasculature can potentially be injured by injudicious use of energy, including monopolar as well as bipolar cautery, laser, clamps, heat and seal devices. One must not just understand how far an instrument’s energy can travel, but must also examine the instruments with every case to ensure they are working properly. Whenever there’s been inadvertent injury to a significant blood vessel, bowel or major organ, the laparoscopic surgeon must decide whether or not to repair it laparoscopically, convert to open procedure to repair it, or seek emergent intraoperative assistance from a specialist. The decision will clearly rely on the severity of injury as well as skill level of the laparoscopic surgeon. Surgeons must be sure of their skills when repairing surgical errors without seeking further assistance. In addition, improperly positioned sutures can lead to bleeding, pain, bowel damage, and herniation.

POSTOPERATIVE COMPLICATIONS

Most laparoscopic patients possess fairly uneventful recoveries; however, it is not always true that they experience less discomfort than patient’s going through exactly the same process with open procedure. Generally speaking, the postoperative laparoscopic patient should clinically improve each day. However, patients do develop an ileus with symptomatology. Patients with acute bowel injuries will present with traditional and/or nontraditional signs and symptoms, thus it is mandated for the surgeon to practice maintaining a high clinical index of suspicion for intraoperative injury with regard to laparoscopic patients who initially are doing fine and then suddenly enter clinical decline.

CONCLUSION

Laparoscopy has become a pillar within the surgical arena. Even though it is popular among physicians and patients, the risks as well as complications offer a similar experience although not identical to open procedures in regards to the same organs. Although there has not been a surge within claims related to laparoscopic methods in the literature; nevertheless, you will find multiple problems and injuries in published sequence. Laparoscopy typically results in less loss of blood and improved visual imagery due to zoom provided by the actual laparoscope. Nonetheless, complications and accidental injuries do occur throughout entry, dissection, as well as closure. Conversation, informed consent, as well as documentation are the secrets of preventing as well as defending statements of medical malpractice and wrongful death.

 

Kathleen A. Mary, RNC, Legal Nurse Consultant Certified is an honored medical expert and lifetime clinical scholar valued immeasurably by her plaintiff and defense attorney-clients as a time/cost-efficient asset to medical malpractice, personal injury and product liability claims. Kathleen provides flawless investigative navigation of meritorious complexities, meticulous comprehensive medical record reviews, locates trusted preeminent experts, is a recognized medical researcher and lifetime standard of care clinical consultant. For over 25 years, 100% of Kathleen’s cases (hundreds) have been positively settled without trial. Please contact Kathleen for your next medical-legal case.  

 

 

 

Obstetrical Medical Malpractice │ Delay in Treatment of Fetal Distress Allegations

Posted by Kathleen on October 22nd, 2017


boat1The most frequent allegation in obstetrical medical malpractice claims is delay in treatment of fetal distress. Standard of care analysis of these professional negligent cases revealed that the most common reason for the delay was physician failure to timely intervene when presented with Category II or III fetal heart rate (FHR) tracings predictive of metabolic acidemia. Other factors contributing to maternal-fetal injury in cases of failure to timely recognize and failure to timely intervene with fetal distress include:

  • Improper selection and management of therapy when faced with maternal illness or signs of chorioamnionitis.
  • Inadequate patient assessments when fetal monitor tracings indicated that the neonate’s conditions were deteriorating.
  • Lack of communication among physicians and nurses when a member of the team recognized distress.
  • Inadequate patient monitoring.

 

Kathleen A. Mary, RNC, Legal Nurse Consultant Certified is an honored medical expert and lifetime clinical scholar valued immeasurably by her plaintiff and defense attorney-clients as a time/cost-efficient asset to medical malpractice, personal injury and product liability claims. Kathleen provides flawless investigative navigation of meritorious complexities, meticulous comprehensive medical record reviews, locates trusted preeminent experts, is a recognized medical researcher and lifetime standard of care clinical consultant. For over 25 years, 100% of Kathleen’s cases (hundreds) have been positively settled without trial. Please contact Kathleen for your next medical-legal case.  

 

CRITICAL CHEST RADIOGRAPHS: CLINICAL MISDIAGNOSES ASSOCIATED WITH MEDICAL MALPRACTICE

Posted by Kathleen on October 16th, 2017


boat1Many chest radiographs are first viewed by non-radiologists, who must be able to quickly recognize critical findings that identify patients who need emergent care. The following clinical diagnoses are often associated with medical malpractice cases:

  1. Pneumothorax occurs when air fills the space between the parietal and visceral pleura. A primary spontaneous pneumothorax occurs in persons without underlying lung disease and in the absence of an inciting event, while a secondary spontaneous pneumothorax occurs in those with underlying parenchymal lung disease (eg, chronic obstructive pulmonary disease, pulmonary fibrosis). On a chest radiograph, a pneumothorax may be identified by a discrete shadowed line beyond which no lung markings are present. They most commonly occur in the lung apices, which are the least dependent part of the lung. However, on supine radiographs, pneumothoraces may be subpulmonic or anteromedial in location. Comparison between inspiratory and expiratory films may aid in detection.
  2. Tension Pneumothorax develops when injury creates a one-way valve for air to enter, but not leave, the pleural space. Clinical features are contralateral tracheal deviation, ipsilateral hyperresonance to percussion, ipsilateral decreased breath sounds, distended neck veins, and hypoperfusion. The typical radiographic findings are ipsilateral lung collapse with widened intercostal spaces and contralateral mediastinal deviation. With a left hemithorax, the left hemidiaphragm may be depressed, but the liver prevents this from developing on the right side.
  3. Pneumomediastinum is free air in the mediastinal structures. It most commonly occurs following trauma or iatrogenic injury to the esophagus or adjacent alveoli. On chest radiography, free air may outline anatomic structures. Common findings are a thin line of radiolucency that outlines the cardiac silhouette, vertically oriented streaks of air in the mediastinum, a double bronchial wall sign, or lucency around the right pulmonary artery—the “ring around the artery” sign. Air is most easily detected retrosternally on lateral chest radiographs. Air is fixed in a pneumomediastinum and does not rise to the highest point.
  4. Airway foreign bodies are most often found in very young children—most commonly in the right mainstem bronchus, due to its posterior location, shallow angle to the trachea, and wide diameter. With non-radiopaque foreign bodies, indirect signs of aspiration include focal overinflation from partial obstruction or atelectasis from more complete obstruction.
  5. Pneumoperitoneum (air within the peritoneal cavity) most commonly results from perforation of an abdominal viscus. On upright chest radiographs, dark crescents of air will separate the liver, spleen, and intestines from the diaphragm. Since air will accumulate in the uppermost portion of the abdominal cavity, patients should be kept upright for at least 5 minutes before the image is taken, to ensure adequate air migration. Sometimes, air inside and outside of the bowel outlines the intestinal wall—the double-wall or Rigler sign.
  6. Pericardial effusion results from the accumulation of fluid within the pericardial space. The classic finding on a chest radiograph is an enlarged globular cardiac silhouette, the so-called water-bottle heart. However, if the fluid accumulates rapidly, then minimal cardiomegaly may be present. Other potential findings include pleural effusion and rarely pericardial calcifications. By standard of care, cross-sectional imaging may be needed to differentiate a pericardial effusion from cysts, diverticula, or other masses.
  7. Acute Respiratory Distress Syndrome, the most common findings on chest radiographs are bilateral, predominantly peripheral, asymmetric consolidations with air bronchograms. Septal lines and pleural effusions are uncommon. Early findings during the exudative phase are bilateral consolidations that obscure the pulmonary vascular markings. These opacities extend to more extensive diffuse consolidations that are typically asymmetric. In the subsequent fibrotic stage, a diffuse interstitial appearance may develop. Most radiographic abnormalities begin to resolve after 10-14 days if the patient survives.
  8. Thoracic Aortic Aneurysms are defined as a greater than 50% aneurysmal dilatation of the normal ascending thoracic aorta, aortic arch, or descending thoracic aorta. The descending thoracic aorta is the most common site. On chest radiographs, the most common findings are a widening of the mediastinal silhouette, enlargement of the aortic knob, and tracheal displacement. Other radiographic findings include a double-opacity appearance to the aorta representing true and false lumens, localized bulges along the aortic contour, and a disparity in the caliber of the descending and ascending aorta.
  9. Diaphragmatic Hernias occur when a defect in the diaphragmatic wall allows the herniation of abdominal contents into the thoracic cavity. Most are on the left side, possibly because of either weakness of the left hemidiaphragm or protection of the right hemidiaphragm by the liver. On chest radiographs, asymmetry of a hemidiaphragm or changing diaphragmatic levels may be present. A retrocardiac opacity may be the first sign of a developing hernia. Gas-filled organs or a nasogastric tube within the thoracic cavity will confirm the diagnosis. Solid abdominal organs will appear as mushroom-shaped.
  10. Congestive Heart Failure produces a number of typical findings on chest radiographs. With cardiomegaly, the cardiothoracic ratio increases to greater than 50% on a posterior-anterior chest radiograph. Kerley B lines may be present on the lung periphery due to interlobular septal thickening. Accumulated pleural fluid may blunt the costophrenic angles or cause large pleural effusions. Pulmonary edema may cause bilateral increased lung markings in a perihilar, or bat-winged, distribution. Increased pulmonary capillary pressure causes the upper lobe vessels to be equal or larger in caliber than the lower lobe vessels, referred to as cephalization.
  11. Aspiration Pneumonia is an infectious process caused by aspirated oropharyngeal flora or gastric contents. It is differentiated from aspiration pneumonitis, which is caused by direct chemical insult from the aspirated material. Typical findings on chest radiographs are bilateral opacities in the middle or lower lung zones. In the acute phase, transient infiltrates or lobar consolidation may be present, while chronic aspiration may appear as a solidified mass.
  12. Flail Chest is the paradoxical movement of a segment of chest wall caused by the fracture of at least 3 ribs broken in 2 or more places. The segment is drawn inward during respiration by negative intrathoracic pressure, and pushed outward during exhalation. Flail chest most often results from significant blunt thoracic trauma. On chest radiographs, rib fractures may be very difficult to assess, requiring multiple oblique views and close attention to detail. By standard of care, if fractures are suspected but cannot be confirmed with chest radiographs, a computed tomography (CT) scan may be needed. As flail chest is a life-threatening condition with up to 15% mortality, prompt diagnosis is mandatory.
  13. Pulmonary Embolism diagnosis is typically confirmed by CT angiograms and ventilation-perfusion scans. Chest radiographs are usually normal, but may show a Westermark sign (dilation of pulmonary vessels with a sharp cutoff), a Hampton hump (a wedge-shaped consolidation in the lung periphery caused by pulmonary infarction and atelectasis), or a small pleural effusion and an elevated diaphragm.
  14. Atelectasis is defined as diminished volume affecting all or part of a lung typically from alveolar collapse. Atelectasis may be obstructive from reabsorption of gas from the alveoli or nonobstrucive from compression, loss of surfactant, replacement of parenchymal tissue by scarring, or loss of contact between the parietal and visceral pleura. Chest radiograph findings vary, depending on the location and extent of involvement. Lobar collapse may present with displacement of fissures, opacification of the collapsed lobe, and ipsilateral mediastinal shift, rib crowding, elevated hemidiaphragm, and volume loss. Atelectasis of a lobe adjacent to the heart may obscure the adjacent heart border.
  15. Appropriate Placement of an Endotracheal Tube is initially evaluated with bilateral auscultation and usually a carbon dioxide detector, however a chest radiograph is routinely performed by standard of care for confirmation. Endotracheal tubes have a radiopaque strip impregnated along one side to aid in evaluation. The tip of the tube should be 2-6 cm above the carina. At this position, the tip will provide adequate ventilation when the tube is shifted during neck flexion or extension. If the tube is positioned too deeply, there may be selective intubation of only one lung, which can lead to complete atelectatic collapse of the contralateral lung.
  16. Hydropneumothorax refers to the presence of both air and fluid within the pleural space. It may develop after esophageal rupture, trauma, infection with a gas-forming organism, development of a bronchopleural fistula, or surgery. An upright chest radiograph will typically show a horizontal air-fluid level that extends across the whole length of the hemithorax. For an air-fluid level to be present, there must be both air and fluid within the pleural space.
  17. Left ventricular aneurysm is an uncommon complication after a myocardial infarction, in which weakened myocardial tissue creates a distinctive outpouching of the left ventricle. On chest radiographs, the total heart size will be enlarged with a prominent bulging of the left heart border. On lateral radiographs, there will be distortion of the lateral heart profile, either anterior or posterior depending on the region of outpouching. In some cases, a rim of calcification may be present outlining the aneurysm itself.

 

Kathleen A. Mary, RNC, Legal Nurse Consultant Certified is an honored medical expert and lifetime clinical scholar valued immeasurably by her plaintiff and defense attorney-clients as a time/cost-efficient asset to medical malpractice, personal injury and product liability claims. Kathleen provides flawless investigative navigation of meritorious complexities, meticulous comprehensive medical record reviews, locates trusted preeminent experts, is a recognized medical researcher and lifetime standard of care clinical consultant. For over 25 years, 100% of Kathleen’s cases (hundreds) have been positively settled without trial. Please contact Kathleen for your next medical-legal case.  

 

UNDERSTANDING CARDIOLOGY MEDICAL MALPRACTICE CLAIMS

Posted by Kathleen on July 6th, 2017


boat1It costs about $80,000 to defend a cardiologist in a medical malpractice claim resulting in payment—nearly four times the cost in ophthalmology, the least expensive specialty to defend. That is a great deal of money, and it likely heightens cardiologists’ motivation to do everything possible to avoid liability lawsuits, while still doing what is best for the patient. All future lawsuits cannot be avoided, but understanding the clinical circumstances of previous suits may help minimize their prevalence and impact, while still allowing cardiologists to provide excellent healthcare.

A recent examination of closed claim data from The Doctors Company, the nation’s largest physician-owned medical malpractice insurer, helps identify steps cardiologists can take before, during, and after patient interactions that meet the twin goals of optimizing patient care and protecting themselves legally, particularly in the face of inevitable complications and other poor clinical outcomes.

Cardiology may hold a unique place in the medical malpractice landscape because of its diverse set of physician-patient interactions. Not only do they diagnose conditions that are often life-threatening, they also perform invasive procedures on some of the very sickest patients. The wide diversity of these cases may make this specialty a particularly good model upon which to extrapolate conclusions about the liability pitfalls facing all clinicians. Analysis of the details of 429 closed claims occurring in cardiology between 2007 and 2013 offers insight to all physicians about the types of clinical scenarios that create the largest potential liability risks.

Topping malpractice claims is failure of diagnosis, which was alleged in 25% of closed cases. While myocardial infarctions are sometimes misdiagnosed in cardiology—and even more frequently among physicians without specialized cardiac training—the new data show cardiologists are more likely to overlook non-cardiac diagnoses that present similarly to a cardiac ailment, such as pulmonary embolism, aortic dissection, or even cancer.

Lawsuits stemming from procedural or surgical complications are the next most prevalent, which is both unsurprising and frustrating to surgeons. Even the most skilled and experienced proceduralist will have complications; in an ideal world, expected complications should not, in and of themselves, trigger a lawsuit. Unfortunately, they often do.

For interventional cardiologists, lawsuits stemming from vascular access complications—retroperitoneal bleeding, in particular—represented the primary source of liability danger, with a close second being other vascular complications such as embolism or coronary artery damage.

Among electrophysiologists, three complications represented the bulk of malpractice suits: 1) arterial laceration during a pacemaker implantation or electrophysiology study, 2) atrioventricular node damage during ablation that required pacemaker placement, and 3) pulmonary vein stenosis after ablation. Transesophageal echocardiography, though not an invasive vascular procedure, had two primary liability risks—first, lawsuits after esophageal perforation, and second, neurological damage caused by neck flexion in patients with undiagnosed epidural abscess.

The data also shows that prescribing certain medications should set off “liability alarm bells,” since improper medication management accounts for the fifth most common allegation. For example, the significant lung and liver side effects from amiodarone can be a fertile ground for lawsuits from patients who may blame the physician years after the drug was first prescribed. Similarly, the use of Coumadin and Heparin often places cardiologists between a rock and a hard place. The drug’s narrow therapeutic window can create liability problems for physicians who need to decrease a patient’s stroke risk, but may end up causing severe bleeding.

Cardiologists should become more aware of the most prevalent types of diagnosis or procedural errors and engage in meticulous informed consent. That same meticulous attention must be paid to documentation, workup, and follow up after a complication occurs. Failing to act expeditiously—by not ordering a CT scan to evaluate a possible retroperitoneal bleed, for instance—may turn a routine complication into a lawsuit. Rigorous documentation is always needed, but it’s particularly needed when physicians choose a high-risk, liability-prone medication. Prescribing the drug is perfectly acceptable, of course; it’s simply important to inform the patient about its inherent risks and vigilantly monitor for side effects. Lastly, non-cardiac issues need to be carefully watched, particularly when following up on a possible cancer diagnosis or when prescribing non-cardiac medications.

It’s notable that the top reasons for cardiology lawsuits diverge so widely, encompassing both diagnosis and procedure allegations. This suggests there is no single aspect of the practice of cardiology that is particularly liability-prone. Different types of cardiologists, both proceduralists and non-proceduralists, face different types of dangers, and need to be recognized.

Kathleen A. Mary, RNC, Legal Nurse Consultant Certified is an honored medical expert and lifetime clinical scholar valued immeasurably by her plaintiff and defense attorney-clients as a time/cost-efficient asset to medical malpractice, personal injury and product liability claims. Kathleen provides flawless investigative navigation of meritorious complexities, meticulous comprehensive medical record reviews, locates trusted preeminent experts, is a recognized medical researcher and lifetime standard of care clinical consultant. For over 25 years, 100% of Kathleen’s cases (hundreds) have been positively settled without trial. Please contact Kathleen for your next medical-legal case.