Stroke and CHI – Key Concepts for Legal Professionals

Stroke and CHI – Key Concepts for Legal Professionals.

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Stroke and CHI – Key Concepts for Legal Professionals

Head injuries or brain damage can occur anywhere – in the workplace, in an MVA, in medical malpractice, toxic torts, a domestic fall, and environmental exposures.

Litigated head injuries generally arise from two sources:

1. Accidents
a. blunt trauma (fall, violent blow or MVA)
b. penetrating trauma (gunshot)

2. Medical causation (stroke)
a. ischemic (a clot blocking blood flow to a major artery)
b. hemorrhagic (rupture of a major artery causes damage to the brain)
c. TIA or Transient Ischemic Attack (symptoms resolve within 24 hrs)

In all instances, brain injury is affected by blood: either blocked flow (ischemia) or bleeding that puts pressure on another area, damaging tissue. The location of the injury is the most important determinant of the severity and likelihood of recovery.

Key Concepts

• Rate and degree of recovery after brain injury is quite variable

• The most common form of traumatic brain injury is the subdural hematoma (SDH), with a mortality rate ranging from 50 – 90%. A significant percentage of these deaths result from the pressure on the brain that develops in the days after injury. Treatment of the SDH depends upon the location and age of the lesion. Because bleeding is not static, “Early and sometimes repeated CT scanning may be required in cases of clinical or neurologic deterioration, especially in the first 72 hours after head injury, to detect delayed hematoma, hypoxic-ischemic lesions, or cerebral edema.”

• Approximately 20-30% of patients will recover full or partial brain function. However, post-operative seizures are relatively common in these patients.

• Although recovery from TIA (transient ischemic attack) occurs within 24 hours, these patients may be at a high risk for falls if they may regain mobility before being aware of their surroundings.

• Strokes arising from blood clots usually require anticoagulation therapy to prevent further clotting, but improper medication management can result in a fatal hemorrhage

• Because patients can “go bad” quickly, frequent monitoring of vital signs, ICP (intracranial pressure) measurements, lab values, pupil checks and level of awareness is crucial.

• A critical part of assessment includes changes, even by one point, in the Glasgow Coma Scale

The Glasgow Coma Scale (GCS) numerically represents the level of consciousness and is based upon a 15-point scale for estimating and categorizing the outcomes of brain injury. The patient who is unable to respond verbally or follow commands can nonetheless have a reflexive response to painful stimuli. Families do not appreciate this form of assessment, but the patient’s physical response tells a great deal about how the brain is processing this noxious stimulus. The following signs are associated with a poor prognosis:

• A Glasgow Coma Scale less than 8 in the field
• A Glasgow Coma Scale less than 5 in the ER
• Unequal/changing pupil size
• Motorcycle accident (direct head impact and no airbag)
• Problems with ventilation, further depriving the brain of oxygen

A patient with an acute and severe brain injury may be placed into a medically induced coma to protect and allow the brain to rest by slowing metabolism. Mechanical ventilation controls oxygen and carbon dioxide levels that can aid in reduction of swelling, and sedation allows an override of the patient’s breathing, which is often labored and dysfunctional.

Pain should be managed effectively because it can lead to a rise in intracranial pressure. An intubated patient is treated with short acting sedation and analgesia until time for weaning.

Claims for pain and suffering in the unconscious patient should consider:

• The victim’s awareness of impending danger prior to the head injury (an assertion of this awareness has been successfully argued even with death cases)

• Successfully communicating to a jury the difference between purposeful movements and reflex, and

• Evaluation of post-injury residuals established by Medical Cost Projection or Life Care Plan.

Putting post-injury impairment into perspective, it is very important to know the level of prior intellectual and emotional functioning. This information is sought by defense counsel in quantifying financial responsibility, and is equally important to plaintiff’s counsel in supporting a reasonable demand.

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Alice Adams is a veteran RN who has cared for many acute head injury patients. She has been a legal nurse consultant since 2006 and lives in Atlanta, GA. She evaluated the injury cases in the 2007 Bluffton University Baseball team’s tragic accident and fatalities, and is very active compiling Medical Cost Projections and providing medical analysis for >40 attorneys and law firm.

http://www.aliceMadams.com nurseatlanta@gmail.com 404.771.5155

Questions from Jurors are GOOD, Period.

Really loved this blog.

Not allowing jurors to ask questions is akin to not allowing patients to ask questions of their doctors. We always encourage patients to write down their thoughts before their appointment, lest they forget something critically important.

And honestly, twelve pairs of fresh eyes and ears are bound to think of something that a team of attorneys may have overlooked after months or years of honing in on a theme.

Thank you for allowing a repost.
Alice

Juryology: Art & Science of Jury Persuasion

Pulp Cover_Juror QuestionsThere’s a story in the July 21 online edition of the Boston Globe about a trial in which jurors have asked 281 questions, and in my opinion, the piece skews rather negatively about the whole practice of allowing jurors to ask written questions during trials. That’s wrong: Juror questions are a good thing for you, Counsel, and you should be enabling them in every one of your trials.

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PTSD – Part One: Causation and Symptoms

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Diagnostic Confusion

One would think from the number of PTSD diagnoses made by family physicians, orthopedists, and neurologists that this condition is rampant if not inevitable for any serious personal injury. It is not that simple.

Posttraumatic Stress Disorder as a diagnosis emerged after the Vietnam War. Prior to the then, “shell-shock” was the terminology used in the WWII and Korean wars. The Diagnostic and Statistical Manual (DSM III) classified the diagnosis as an anxiety disorder, and further refined diagnostic criteria in subsequent editions. The diagnosis as it exists in today’s DSM-5 utilizes the most specific criteria yet, re-categorizing PTSD as a stress (trauma) related disorder.

In most States, PTSD (or any other mental injury) is not compensable under workers’ compensation without a preceding physical injury. Nonetheless, some employers will authorize an evaluation for a significant emotional trauma like a robbery, even in the absence of tissue damage. Morally, it seems the right thing to do, and from a legal (perhaps jaded) perspective, an employer who offers treatment under workers compensation may be shielded from liability.

You may be bringing or defending a claim of Posttraumatic Stress Disorder. While diagnosing the disorder is a clinical process, as you weigh the evidence for likelihood of PTSD, here is some data that may guide your assessment.

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More Than One Form of PTSD

If a trauma occurred more than three days but less than four weeks ago, the diagnosis is Acute Stress Disorder.

This is not to be confused with Posttraumatic Stress Disorder – Acute, meaning the symptoms have been present between four weeks and three months.

Posttraumatic Stress Disorder – Chronic means the symptoms have been present longer than three months.
Posttraumatic Stress Disorder – Delayed Expression applies to symptoms that first arise > 6 months after the trauma.

Further refinement of the diagnosis depends upon severity and degree of impairment in functioning. Extreme symptoms may include depersonalization, or the feeling of being an outside observer of one’s body; derealization, or unreal and dreamlike surroundings; both are symptoms and forms of Dissociative Symptoms. Children under 18 are diagnosed by a different set of criteria and they are very sensitized to the traumas encountered by their parents.

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Symptoms & Diagnosis

In personal injury claims, the diagnosis of PTSD is commonly associated with motor vehicle accidents, fires, airplane incidents, amputations, and assaults. Chronic back pain from an injury does not result in PTSD unless the injury itself was traumatic (such as falling from height or being struck by a car).

What are the criteria for a valid claim of Posttraumatic Stress Disorder, and why is the diagnosis so often misapplied by primary physicians when pain is the only complaint? Rather than dispute what PTSD is not, let us examine the eight criteria for a valid diagnosis of PTSD:

A. There must be a triggering event: exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways:
i. Direct experience of the event
ii. Witnessing the event as it occurred to others
iii. Learning that the (accidental or violent) event happened to a close family member or friend
iv. Repeatedly experiencing personal (not via media) exposure to the trauma (such as 911 first responders)

B. A diagnosis of PTSD requires one or more of these symptoms be present following the event:
i. Recurrent intrusive memories that are involuntary
ii. Nightmares of the event –police officers may dream that their family is in great danger and they are powerless to save them.
iii. Flashbacks – the person feels or acts as though the event is happening again
iv. Extreme psychological distress at exposure to internal or external cues of the event (smells, sounds)
v. Extreme physical reactions to internal or external cues of the event (GI upset or vomiting, for instance)

C. The patient persistently avoids reminders of the event in one or more ways:
i. Avoids memories of the event in all forms
ii. Avoids external reminders of the event (people, places, objects, etc)

D. Changes in mood or cognition in one or more of the following ways:
i. Amnesia for important aspects of the event
ii. Pan-negative beliefs about self or the world
iii. Irrational self-blame
iv. Persistent negative emotions of fear, anger or shame
v. Withdrawal from activities
vi. Withdrawal and detachment from others
vii. Anhedonia or the inability to experience happiness or pleasure

E. One or more of the following behaviors are atypical in presence or severity prior to the event:
i. Extreme irritability or aggression
ii. Reckless or self-destructive behavior
iii. Extremely on guard for surroundings/safety
iv. Exaggerated startle response
v. Difficulty concentrating

F. The symptoms in Criteria B-E have lasted > 4 weeks

G. The symptoms are severe enough to impair functioning in social, occupational or other areas of functioning

H. The symptoms are not the result of medication or other medical conditions

Next time: Treatment and Planning

With the Right Chronology, You too May Enjoy a Deposition

Last week, I had fun.

I manage my husband’s forensic psychological practice, and last week he had a deposition. He loves depositions. Really.

The data he needed to review, however, was oppressive; he had performed five Fitness for Duty evaluations over 18 months on a professor not well enough to teach three out of those five times. Between each visit were innumerable telephone calls alternating between anger and accusations, anxiety and fear.

Five charts to organize, papers to shuffle, and “where did I see that?” I surprised him with the same work I have provided my attorneys for years – a medical chronology. Five charts became a five-page table arranged in SOAP format– Subjective, Objective, Assessment, and Plan. I was a hero.

Deposition Day: the attorneys arrive with their respective armload of records, between them producing twenty exhibits. In short order, my husband had distributed a copy of my chronology to both attorneys and ten minutes later, no one referenced their paper charts. My chronology was now Exhibit #21 and provided the focus for the next 90 minutes. The defense and plaintiff attorneys huddled together and swore they had never seen such a wonderful document.

How is that even possible? How do attorneys enter a deposition without this organization? These attorneys specialize in employer law, human resources, EEOC and civil rights violations, and chronologies were not part of their repertoire.
I really should not repeat the inappropriate comments from my husband during deposition. A few were on the record; more were off, and all produced peals of laughter that emanated down the hallway. Work should not be this much fun.

The reward for my chronology could well be a notice of deposition to testify as a fact witness. That is perfectly okay – I can just reference my own chronology.

The Autopsy – a Dying Recommendation

In recent decades, there has been a marked drop in autopsy requests – an unfortunate occurrence. In the distant past, any death within the first 24 hours of admission triggered an autopsy. Any unexplained death in or out of the hospital; any accidental death with questionable etiology required an autopsy. JCAHO required 20% of hospital deaths to undergo autopsy as part of hospital accreditation; that requirement ended in the mid 70’s.

One objection to autopsy comes from families and we can well understand their reluctance. The loss is acute and painful; the thought of mutilating a loved one overrides the practical need to identify the cause of death.

In my review of medical records, an autopsy trumps any postulation by a treating physician. Why? Because when a patient is gravely ill, they often have a number of morbid conditions, any one of which could be fatal. A physician has the natural tendency to see the cause of death from the perspective of their specialty.

Virtually useless is the Death Certificate. Death certificates do not provide root cause, only an end result. Respiratory or cardiac arrest is inevitable in death, but those diagnoses provide no etiology; they cannot address the “why” of death.
If an employee dies in the course of work, has an MI, stroke or other “illness death”, an autopsy can offer the evidence needed in an otherwise uphill battle for causation.

In negligence or malpractice death claims an autopsy is invaluable, but all too often the family’s last concern is dissecting the cause. When questions later arise, that most valuable source of information – the patient and their true cause of death – is irretrievably lost.

From a public safety perspective, we can only speculate on the number of infectious diseases, chemical exposures and related information that may be lost.

Regardless of JCAHO recommendations, it is incumbent upon healthcare professionals to offer this option when the cause of death is not crystal clear. “Natural causes” is the most frustrating and misleading nomenclature in the healthcare dictionary.