This Could Be You

Part One: Yes, I am talking to YOU

Do you consider yourself a good nurse, or put another way, would you want your family taken care of by someone just like you? Do you feel comfortable teaching new nurses “how we do it” at your hospital, or on your infusion team, or in your home health care agency or nursing home? I am willing to bet that you can recognize deviations in care, and recognize good care when you see it, and yet, let’s be honest. 99.9% of “us” nurses get the willies when we think about testifying in court. A part of this fear is the belief that we might find ourselves being deposed or on the witness stand, defending our own actions. Talk about a knuckle-biter.

Well, take a step back from that ever-present awareness that you could err, and think about the nurse who already accused of making a mistake and causing harm to a patient. Doesn’t she need help?

Who is that nurse? Not necessarily someone in PACU or CCU, but the nurse on the floor – the one giving or supervising tube feedings, suctioning an ET tube, helping a patient to the bathroom or pushing meds in an IV. Does that sound like anyone you know? In this world of computerized documentation, meant to make our job straightforward (or someone’s job, at any rate), you know how easy it is to miss a check box even though work was done – your Risk Management department delivers this message like your job depends upon it. Oh.

If you were the nurse whose care was being questioned, who would you want on your side? Who else, but another nurse who works in the same environment you do, who understands the rapid pace and demands upon your time, the responsibility for supervising the actions of others and the potential consequences of being nothing more than “there” at the time an event occurred.

Your nursing experience is what makes you so valuable to the legal system and fellow nurses, because you do not live in a world of textbooks and online research.

If  asked to review the medical records of the patient harmed in the hospital or any other setting, would you know how to do that? Of course you would; you know what belongs in a chart and therefore you know what is missing when you (don’t) see it.  Chances are quite high that if someone asks you to serve as an expert witness, harm did occur, because attorneys are not in the business of spending upwards of 100k to try a case that has no injury. Injury and merit, however, are not synonymous.

The question you would be asked is not “did a bad outcome occur”, but “did the bad outcome arise as a direct result of this nurse’s (in) action”? Can the nurse’s care be rightfully defended, who else was in the chain of command, and most importantly, was the standard of care met? Remember that nurse experts are not being asked to diagnose a condition; they are being asked what a reasonable and prudent nurse in the same setting would have done.

Next time, Part Two: When the shoe is on the other appendage.

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I See How It Is

Occasionally, rarely, I have an “ah-ha” moment. This is one of those moments.

Today I engaged in a very interesting back and forth with a nurse-turned-attorney who was polling LNC fees across the country. He lives in a very economically depressed part of the U.S., and attorneys are loath to spend even 30/hr for a legal nurse consultant, much less the 110-125 most of us charge.

Yet, even in his economy, those same attorneys do not blink at paying paralegals 75/hr and I hear the average billed wage for paralegals nationwide is 95/hr.

And I know why.

Attorneys know the value of a paralegal who can do much of their work. The paralegals perform a huge amount of the legal (a.k.a. leg) work behind complaints, interrogatories and depositions. They know what documents to request, keep track of deadlines, arrange the attorney’s schedule and pay attention to the minutiae that is oh-so painful to most attorneys. They are time-keepers, email overseers and meeting coordinators. They are necessary.

Here is my”ah-ha”. Legal nurses do the same thing. The difference is that they handle medical analysis, chronologies, expert location, disease comprehension, accident reconstruction, trial exhibits, statistical research and analysis of covariance. I’m not entirely sure what the latter is, but my husband pulls it out of his academic hat every time one of our children complains about a statistics course. Legal nurses take the pain out of producing medical questionnaires and lines of questioning for physician depositions, and make sure that the attorney knows exactly what records to request, what is missing, and what is nonsensical.

So clearly, my course is simple. All I need to do is convince the uninitiated attorney that when medical issues are involved, the value of a legal nurse equals that of his paralegal. In this parallel universe, my greatest advocate is the paralegal, who has many more things to do than decipher a medical record or try to construct a chronology around a critical event, or coax an expert down out of a tree.

Nurses and paralegals. Unite.

Offshore Record Reviews

Is offshore outsourcing the future of medical records services? I do not think so; the purpose of a medical chronology is to isolate critical data for the attorney and his experts.
Every attorney wants a focused chronology that isolates relevant facts with an explanation of why that fact is important. This allows them to formulate questionnaires and affidavits and prepare for depositions. They do not want hundreds of hours of billing.
The reason there are thousands of pages is because facilities, hospitals and providers are asked to produce each and every document in their possession. An all-inclusive compilation of thousands of pages contains lengthy and irrelevant information, making it difficult for an attorney to find what s/he is looking for. This type of chronology requires only literacy, not discrimination on the part of the reviewer.
By contrast, nurses know hospital and office records, abbreviations and handwritten documentation, and we can weigh care delivered against known standards and guidelines. We are selective in the data extracted, and concentrate on the seminal event while noting pre-existing conditions and discrepancies in care. We do not skip pages that are difficult to decipher and we scan, choose and discard data rapidly. The merits or defense of a case take shape during this review, and those findings are shared immediately, as well as requests for missing documentation.
Without this informed review of records, the attorney is left with hundreds of pages of data that is a timeline, not a focused evaluation. Unless we go to a PCS-based compensation system for medical malpractice, I do not see offshore outsourcing replacing legal nurse reviews.



I am blessed, and if you are reading this now, you are also blessed. We both have electricity, internet access, computers, an education, and by default, the ability, or at least the opportunity, to “make something of ourselves”.

I forget about that sometimes, but all it takes is a little change to remind me. The electricity just returned after being off for four hours. Four hours, not four days. Suddenly I was excommunicated (the Catholic in me) from hundreds of people I may never meet, but are my friends by every definition of the word.

Gone was the air-conditioned comfort, reading lights, Netflix and worst of all, Dogs of War or whatever that Xbox game is that makes my teenage son scream like a little girl with his online gaming friends.

Might as well go to bed, which I did, but I have never noticed how quiet the house is without the sound of the air conditioner, fan, or my woosher (the civilized world calls it a sound machine, but it will always be my woosher, tuned to the ocean setting that reminds me of Sanibel).  What was left? The persistent sounds my dog makes in his undisturbed sleep – little snores, dry swallows, and an assortment of unidentified noises that jolt me into awareness at the precise moment I am falling asleep.

“Count your blessings”, “things could be worse”, “be glad you are not that one”, “at least you have your health”…things people say to comfort each other. In times of disaster, people must reach very deeply to find their gratitude but most will succeed. “At least we have each other”, as they mourn the loss of their home. These expressions are not platitudes; they are truths that guide our lives.

I know that I am spoiled when my biggest complaint is bemoaning the passage of time and youth, and I will spend more time being grateful, I promise. Although…I can still hear my dog swallowing above the sound of the woosher. I should wake him up and remind him that he too is blessed to have electricity, and that porcelain thing he is so fond of using as a water bowl.

Closed Head Injuries & Strokes: A Primer for the Legal Professional

Closed Head Injuries & Strokes: A Primer for the Legal Professional

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 often arise from two sources:

  1. Accidents
    1. blunt trauma (fall, violent blow or MVA)
    2. penetrating trauma (gunshot)
    3. Medical causation (stroke)
      1. ischemic (a clot blocking blood flow to a major artery)
      2. hemorrhagic (rupture of a major artery causes damage to the brain)
      3. 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 starves one area while adding pressure to 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, with a mortality rate ranging from 50 – 90%. [1]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.”[2]
    • 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 are at a high risk of falls because 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[3] (GCS) numerically represents the level of consciousness and is based on 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:[4]

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

    A patient with an acute brain injury is often 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.[5]

    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.

    Establishing the presence of pain and suffering in the unconscious patient includes knowledge of impending disaster (even with death cases), knowing the difference between purposeful movements and reflex, and evaluation of post-injury residuals.

    In order to put post-injury impairment into perspective, it is important to know who the patient was prior to injury. This information is sought by defense counsel in the determination of financial responsibility, but is equally important to plaintiff’s counsel in supporting a reasonable demand.

    [1] US Dept of Health and Human Services, ACR Appropriateness Criteria® head trauma. Bibliographic Source(s)

    Davis PC, Brunberg JA, De La Paz RL, Dormont D, Jordan JE, Mukherji SK, Seidenwrum DJ, Turski PA, Wippold FJ II, Zimmerman RD, Sloan MA, Expert Panel on Neurologic Imaging. ACR Appropriateness Criteria® head trauma. [online publication]. Reston (VA): American College of Radiology (ACR); 2008. 13 p. [51 references]

    [3] Herr K, Coyne PJ, Key T, et al. Pain assessment in the nonverbal patient: position statement with clinical practice recommendations Pain Manage Nurs 2006; 7:44–52

    [4] Marion DW, Find all citations by this author (default).

    Carlier PM Department of Neurological Surgery, University of Pittsburgh School of Medicine, PA 15213. Find all citations in this journal (default).

    The Journal of Trauma[1994, 36(1):89-95]

You know you are a Legal Nurse Consultant When:

Here are selected quotes from experienced LNC’s. Read the entire 29 stories of successful legal nurse consultants in our newly released book: The Path to Legal Nurse Consulting: The Collective Wisdom of Successful LNCs.

You know you are a Legal Nurse Consultant when:

Quitting your day job no longer seems impossible.

When asked what you do at a party, you no longer fall over your words.

You actually believe, deep in your heart, that you are as valuable as your brochure claims.

Your attorneys take one look at a case and call you instead of trying to do everything themselves and messing it all up.Your attorney-client emails and says, “The senior partner wants you to look at a set of medical records for deviations in care because as usual, we don’t have any idea.”

Your family and friends ask you if you have heard of their doctor and are relieved when you say no.

You learn that the correct answer to almost any question can be “It depends…”

You believe there are actually three sides: the plaintiff side, the defense side, and the truth.

Opposing counsel approaches you after a trial and tries to make small talk then asks for your business card, your experience and if you have an interest in working for the opposing counsel.

You ask someone you know well a question, don’t get a direct answer, and then say, “Would the witness please answer the question?”

Your mailman gives you that look, as he delivers the second file box of records up the two flights of stairs to your front door.

You used to meet malpractice and personal injury attorneys and hope you would never need their help. Now you meet malpractice and personal injury attorneys and are pretty sure they could use your help.

You feel as though butterflies (or worse) will surely fly out of your mouth or behind once you have finally mustered up the gumption to make that first cold call!

You find yourself screaming at the computer screen “No, she didn’t just document that!”

Your attorney says the medical records will be ready in a few days and you go ahead and plan a short vacation, maybe even a long vacation.

Your answer to your kids or husband asking repetitive questions is, “Asked and answered”.

You create a PowerPoint to get ideas across to family and friends.

Your attorney client tells you he couldn’t have won his case without your help and expertise.


Maximizing Your Presence on LinkedIn

It’s very easy to join LinkedIn, but not everyone does it well. Here are a few tips from personal experience.

To me, groups are the heart and soul of LinkedIn. Joining a group says you are interested in the topic area and gives you a valid reason to connect with anyone in the group.

When I receive a connection invitation, I appreciate a personal comment that says I am not part of a general numbers game. When I invite someone into my network, I try to find something about them that I can reference in the invitation that shows I am interested in them personally.

I run several groups on LinkedIn and I appreciate members who post Discussions that stimulate dialogue. I do not appreciate the member who posts repeatedly (there is only so much room on a page before others’ posts get pushed out of sight) or is blatantly marketing a service or product (that one goes to Promotions).

Posting an interesting and relevant article is a safe way to market yourself if you are reluctant to respond to others’ posts.

Congratulating someone in your network when they post an update about themselves is something that not very many people do, so you will stand out in the mind of that person.

When someone writes a recommendation for you and you allow it to appear on your site, return the favor. Ideally, you have asked someone who really knows you or your work; a safe rule of thumb is to only ask for recommendations from people you would be comfortable recommending. An even better rule is to recommend them first. Then send them a personal email telling them you have done so, in case they do not have their account set up for daily alerts.

Lastly, avoid politics or articles that clearly take a controversial social tone. Someone will be offended and there is nothing more uncomfortable than being attacked publicly.

Wait, sorry, one more thing. Critique your profile for grammar and punctuation errors. When you are presenting yourself to the public, it is ridiculously easy to ruin credibility with simple mistakes. Review your profile on a regular basis for errors, or just to make sure that you still feel the same way you did on the day you created it.

There is a group for everyone’s interests on LinkedIn, but these are a few ways to stand out in the crowd.


Words Matter

Recently, a nurse was sharing her angst that attorneys to whom she marketed via email were not responding to her. I have been giving this some thought because it is a situation that many new LNCs experience.

Everyone finds their comfort level in marketing, and chances are, if you are too comfortable, it might be time to change things up a little. This is particularly true if you are comfortable, but your efforts are not producing results.  Although LNCs can market to a variety of settings, let’s focus on marketing to attorneys, and begin by looking at ourselves.

What makes you buy a product that has no entertainment value? Need. You might watch a Bare Minerals commercial and be amazed that makeup can completely cover scarring, but if your skin is perfect, you don’t need to buy the product (and it is costly).  If you suffer from acne scarring or other blemishes, the cost may be irrelevant to the benefit you will gain from having the appearance of smooth skin.

Attorneys are the same way. If you call or visit and they do not see a need for you right then and there, they are going to say things like “I’ll keep your information on file”, or they may be “busy” when you call to schedule an appointment. This is not personal; they are concentrating their time and attention where they perceive a need, and right now, you are not it.

What do you do at this point? Do you simply move on to the next target and never look back? Or do you send them a partial work sample and CV, thank them for taking the time to look at or save your materials, and promise to keep in touch? Do you send them a relevant article a few weeks later and then maybe monthly? Because sooner or later, your name will come across their desk when they need your service, and if they like what they have seen of you, you might land a case.

During all this “down” time that no one needs you, what if they are curious enough to look you up online? What will they find?

If you are on LinkedIn, they should find a complete profile, with picture, your education and work history, hopefully a recommendation or two, and a respectable number of connections. They will look for a link to your website and a clear description of your services. They can only see what you have written.

Here is the crux of my rambling (which is another no-no). How many nurses have your medical knowledge and experience? Thousands.

What sets you apart and makes you special; what will convince the attorney that he needs you and not the others? Presentation, and the ability to communicate are critical to being a successful LNC. If your profile is not complete, if your description of yourself is not well-written, if your writing has errors in grammar or punctuation, or flips between first and third person, or past, present and future tense, you may not find work. To an attorney, words are everything.

Words reflect knowledge and experience, and how you put those words together in a sentence indicates the work product you can provide to an attorney. This is such an important issue that attorneys are constantly learning about the best way to write a brief, develop a line of questioning for depositions, or structure interrogatories to opposing counsel.  They will attack each other’s writing style and word choice, and are chastised by judges for using unnecessarily complex terminology.

Words matter. Attorneys work for their client, whether plaintiff or defense; they can be removed from a case if their work is subpar. This is always foremost in their minds. If your writing is poor, how can they trust you to analyze their case, present data in a clear and logical fashion, and not miss relevant data? How can they be comfortable that you will not represent them poorly to their client?

You cannot make a new client call you, but while you are waiting for the phone to ring, use that time to review your marketing materials – brochures, business cards, CV, sample work product and online profiles. Make sure these items have a common theme, represent your expertise, and do not misrepresent your ability to communicate. Look for webinars or courses that teach you how to write for attorneys.  (There’s probably one right now at, or

There are many ways to write a report or chronology, but none of them include nursing shorthand, medical abbreviations, incomplete sentences and grammatical errors. Find a peer to critique your work and return the favor. If verbal communication is quicksand for you, focus on email and snail mail. Attend law seminars or sit in court and listen to trials, read about affidavits and other legal documents that you may never write but need to understand.  You will feel more confident, be more competent, and have no trouble letting that attorney know that s/he does indeed need you.


The Perfect LNC

Would you like to know what it takes to be a legal nurse consultant? The average LNC will be a nurse with a minimum of five, preferably more, years of clinical experience in the hospital/OR/ICU/CCU or nurse case manager arena. This nurse is intelligent, competent, independent, confident, and willing to try something new despite misgivings. S/he can communicate verbally and in writing.

This nurse has a reliable income stream, because it takes a while to get a business up and running. “Don’t quit your day job” is our mantra, unless you are a salaried employee in a law firm. The panic of economic stress can abort an LNC’s career before it has a chance to succeed.

Here are some of the features that characterize the legal nurse consultants that I know:

  • You take your work home with you – your home will probably be your office
  • You develop marketing skills and become familiar with business sites like Linked In, polish up your resume and think about business cards, marketing brochures, etc.
  • You are comfortable with basic software like the suite of Word programs and Adobe Acrobat, and pay strict attention to your email inbox
  • You develop a style of analysis and critical thinking that allows you to communicate with your attorney, insurer, or whomever is your client
  • You find a niche in which you are comfortable, and make it known that this is where you shine – neonatal, pediatrics, cardiac, wherever
  • You offer informed opinions on LinkedIn or Yahoo LNC Exchange groups so that your name becomes familiar
  • You distinguish yourself from a paralegal; you do not need to know the letter of the law – your value is in your nursing experience and medical knowledge
  • You learn to look beneath the surface of everything
  • You do not stop caring about patients, but you are now an advocate for the truth, a fact-finder, a researcher, a communicator of your findings
  • You learn to anticipate what the “other” side will use to support their position and identify the weaknesses in your case– you do not allow your attorney to be surprised in a deposition or courtroom
  • When you come up against an obstacle, your first inclination is to solve it before asking for help

 Being a legal nurse consultant is not the same thing as being a patient advocate.  It is finding the medical evidence that supports the truth.

 It is about seeing what others miss, and believing in your work product and yourself. Most importantly, it is about learning, because every case is different, research evolves, even standards of care change. No one can assure you of success, but you can be successful if you believe in yourself and are willing to invest the time in preparation. Take advantage of all the free information that is out there, the inexpensive webinars, the textbooks and the conferences. You will never stop learning, and that is the greatest gift of any career.

My Story

Increasingly, nurses contact me for information on legal nurse consulting. This field is too rich and diverse for a simple explanation, and all I can share is my own journey. As Led Zeppelin said, “yes, there are two paths you can go by, but in the long run, there’s still time to change the road you’re on”.

I did not hear the term “legal nurse consultant” until 2005. Until then I had been a nurse – ICU, ortho, pediatrics, psych…from that moment forward, Google was my new best friend.

I looked into various programs that purported to turn me into a legal nurse consultant, indeed a wildly successful one. These programs were legion. Some were taught by universities, either in the classroom or online; others were agencies that offered “specialization” in numerous fields of study, and still others were more concerned with the business and marketing of legal nurse consulting. All offered certificates, but not certification. (The only certification recognized by the American Association of Legal Nurse Consultants is theirs, and you cannot become certified without 2000 hours of LNC work and passing the AALNC course of study. I have the hours, but not the time for studying…perhaps next year.)

I selected a course, learned a great deal, and acquired an impressive string of initials to add to my RN. I stopped using those when I realized they meant nothing. I read Pat Iyer’s Legal Nurse Consulting Principles and Practice, Nursing Malpractice, and Business Principles for Legal Nurse Consultants. I read Betty Joos’s Marketing for the Legal Nurse Consultant, bought a comprehensive handbook of legal terminology, and reviewed changes in nursing standards of care. I did the coursework for SANE certification, bought malpractice insurance, and joined too many organizations. The most useful group I joined was the JERKS, because you can never know too many LNC’s, or have too much advice and support.

I bought a color printer, created and printed a brochure; wrote, and constantly re-wrote, a cover letter to send to attorneys along with my c.v. I designed and printed my own business cards, and developed a website (now on my fourth). I switched from Word Perfect to Word and bought chronology software. I mailed ten packets a week for many weeks before someone called me and it was for the one thing I would not do – provide expert testimony.

Eventually, an attorney called me with three controverted workers compensation cases – cardiac, and he wanted me to help him overturn them. This, I could do, and he still uses my services. I found, however, (being a healthy skeptic), that I really love defense work. First nursing home litigation, then numerous premises liability cases, product liability, slip and falls, mold exposures, wrongful deaths, medical malpractice, World Trade Center merit assessments – each case was, and will always be, unique. The learning curve never flattens out.

I developed a profile on LinkedIn, started several groups, carefully built my network, and joined my local AALNC chapter. I presented a webinar on using LinkedIn and overcame some of my loathing of public speaking. I am president of my AALNC chapter, and our Board produced a very successful regional LNC conference in July. I love this path I have chosen, and I hope the journey never ends.

Finding Work as an Expert Witness

I receive numerous requests from nurses that are experienced in their field and wish to find work as testifying experts. This posting is for those nurses.

While there are publications that will list you for a fee, there are free resources to aid in this endeavor.

One of the easiest ways to make contacts is to join a Yahoo group that is active in the medical/legal arena.  LNCExchange is a moderated group in which nurses, physicians, attorneys and other healthcare specialists post questions to the group.  It is a rich resource for experts because we members will put out a call for a particular specialty, which may or may not be geographic-specific. You can then respond directly to that posting.

Qualifications for an expert vary from state to state and the need changes from case to case.  In fact, I found the following on California’s State Board of Nursing website:

[Recruiting Expert Witnesses

The BRN Enforcement Program is currently only recruiting qualified registered nurses to review case materials, prepare written opinions, and possibly testify at administrative hearings as an Expert Witness for cases involving Botox/Laser/Dermabraision and HIV/AIDS.

Expert Witnesses are paid $75 per hour for case review and preparation of the expert opinion report and $75 per hour plus expenses if called to testify at an administrative hearing.

If you wish to provide this service to your community and be considered by the BRN as an Expert Witness, please verify that you meet the following requirements:

  • A current and active California RN license
  • Ten or more years of experience and expertise in one of the areas or specialties listed above AND current employment in that setting
  • No prior or current charges or discipline against any health care related license in California or in any other place of licensure
  • No criminal convictions, including any that were expunged or dismissed]

Interesting, no?

At a more general level, when I search for an expert,  I need someone who has been active in their field for 3 of the past 5 years. There are variations on this. If someone has a case in which an event happened during a different timeframe, the attorney may want an expert who was active during that timeframe, particularly if different technology or standards of care were in place at the time.

The Sickest People I Know are Nurses

It is true. These are legal nurse consultants, working at the limits of their physical capacity, and never complaining about aches, pains or the horrible nausea from chemotherapy. I have known some LNC ‘s for years before they told me they had cancer or Crohn’s or a debilitating orthopedic condition.

I am fortunate to be in good health. A major cold is enough to stop me in my tracks, each minute feels like an hour, and fleeting stomach upset makes me look twice at staying in bed.

But these nurses. One in particular is a dynamo; she projects positive energy, shares her contacts, knowledge and resources with others, and never complains. She has so much information in her head she should have her own search engine. She is on chemo, and just yesterday, she said to me, “Alice, this chemo thing is not that bad. My sister cut my long hair short so it wouldn’t be a shock to lose it; this Zofran handles the nausea, and those mouth sores respond pretty well to the medicated mouthwash. Anemia and thrombocytopenia will be a problem, but listen; I have a case I’m working on. Let me tell you about it…”

And, off she goes. Within the forums that I frequent, a good percentage of the LNC’s either currently have or have had cancer or other disabling diseases. Undoubtedly, the illness rate is higher than in the general nursing population. They work because they love it, they need the mental stimulation, they have families who depend upon their income, and because they are tough. No one is judging their consult report by how they dressed that day and no one will know if they were too sick to get out of bed when they wrote that excellent report.

They are nurses, and they are tough. If a legal nurse consultant tells you to get over yourself and get on with it, there is a good chance that she is speaking from personal experience. Listen to her.

Plea(s) and Thank You

It is Friday.  Your phone rings at 3pm and a desperate attorney needs an expert by Monday morning.  In reality, he identified the need for an expert weeks ago, but the search was postponed in hopes of mediation or a settlement that did not occur.

Or.  Your own deadline is looming and you know that out there, hidden among the .pdf’s and scientific abstracts, is the data that will bolster your opinion.  You can support or refute a position or diagnosis, determine pre-existing conditions or alternate causation; you just cannot find the authoritative research. 

You put out the call.  Listservs, forums and exchanges exist for such crises and sure enough, other nurses come to your aid.  Within short order, several have emailed you with names, articles, resources, whatever you need, and you can breathe again.  They answered your pleas – did you remember to say thank you?

It is gratifying to help others, and even though you will one day return the favor, the moment for appreciation is now.  Say thank you right away to the person who dropped what they were doing to help you.

Merit in an Upside Down World

As practicing nurses, we take care of the sick, observe them for declines in condition, and rectify the wrongs done by others as a matter of course.  If we put our patients first on a busy shift, our hands are literally full – too full, sometimes, to pick up a pen and document the care we have given.

The result of a horrible day may be a life saved and a catastrophe averted, but if we did not write it down, it simply did not occur years later when our work is reviewed.

This was brought home to me in a case I recently reviewed for merit.  The lack of documentation clearly provided legal support for negligence.  Did I truly believe this patient had gone four hours in the emergency room without one vital sign being taken?  No, I did not.  But two years after the fact, no one can prove those vital signs were taken.

I did know that at the end of those four hours, the patient had crashed.  His first recorded systolic was in the 60’s, he was bleeding out, and he was on a stretcher with the head of his bed elevated to at least 75 degrees.  This was a breach in the standard of care.

The second breach of care was less of a breach and more of an accident – the kind that can occur with any outpatient colonoscopy – but which nonetheless resulted in massive internal bleeding.

The third breach occurred as his circulatory system was overloaded with too much fluid over too short a time for a person with heart disease.  Failure to recognize this resulted in congestive heart failure and pulmonary edema.

The fourth negligent act was failure to recognize the signs of internal perforation with resulting crepitus. Think Michelin Man as he was wheeled off to emergency surgery two hours later.

Any nurse would be appalled and sympathetic to the plight of this helpless patient.

However, as legal nurse consultants, we must step beyond what was done wrong, and focus on the event that definably resulted in permanent damages.  Without those permanent damages, patients are not reimbursed for near-fatal events and a medmal attorney will not take this case.   

Of all the things that happened to this patient, ultimately only one event will matter.  The gap in vital signs that could have deprived his brain of oxygen will account for his residual cognitive deficits.  Deficits mean a loss of earning capacity and a formula by which to assess damages.  That gap of time during which care probably was given but was not charted is the critical event on which this case will proceed, if at all.  A cautionary tale for all of us, and doesn’t that feel a bit upside down?

Cliches of Independence

I have always heard that clichés were the conversational crutches of concrete people; that the truly bright and abstract among us do not think with the thoughts of others. But I have come to believe that behind every cliché is a solid foundation of truth, and the clichés surrounding independent employment are no exception.

It’s “feast or famine out there”. This is true, and truer still is the fact that independent work often results in famine and forgets to feast. For the newly independent legal nurse consultant, know this: never count on work that is promised to you, and never ever turn down work because you think you will be too busy to manage it. The attorney that calls you to check on your availability for a case may sound very sincere, and he may know that he needs your expertise. What he may not know is whether the adjustor that ultimately pays the bill will allow him to hire you. S/he may have miscalculated the tolling of a case, or the client may get cold feet, or simply go elsewhere for legal advice. I have congratulated many new LNC’s who are ecstatic that someone called them after seeing their brochure, email or marketing packet and said “I’ve got a case…”. The LNC will then turn down a job that paid half as much as their independent hourly fee because they want to remain available for this higher paying consult. Do not do this. Do not “count your chickens before they are hatched” for a very good reason; you cannot predict the hatch rate.

Attorneys know this lesson well. The very successful medmal attorney will only take a “case that has legs” (another cliché, although sometimes the legs take cases in the opposite direction). This is an attorney with “deep pockets”; it took me a while to learn all the nuances of that cliché. The majority of attorneys will take all but the most openly hopeless case in the knowledge that you “never know where your next meal is coming from”. They can juggle hundreds of cases if they have good support staff and strong organizational skills, but some will juggle those cases even without the requisite staff and skills, which is one of the reasons the retainer check, records or agreement never arrive as promised.

The other trap for a new LNC is the Friday afternoon call for an expert that is needed immediately. If I could recall the nurse who said it I would give her credit for the following: “Failure to plan on your part does not constitute an emergency on my part.” I really love that sentiment even though it is not a cliché. Fellow nurses, know that with rare exception, last minute requests are the result of poor planning. Poor planning goes hand-in-hand with failure to notify you that “Oh that case settled”. Do not be discouraged. The Declaration of Independence was the beginning of hard work, not the end of it. “Pick your battles wisely”, “Don’t get too big for your britches”, and “Don’t give up your day job” when you choose the route of independent LNC work. It really is a wonderful life.

As I write this, there are four projects that have been promised, three open cases I am working and two more that are in the pipeline. You will notice though, that I have time to write this blog. I have learned not to “put all my eggs in one basket” (clearly, poultry farmers have much wisdom to share). The projects were to be spaced so that one began as another ended, but I have no doubt they will hit in overlapping waves – less of a feast and more like Cloudy with a Chance of Meatballs. Oh well. I could eat.

The Deposition Experience

Today I sat in on the deposition of a woman whose medical records I had analyzed. She was being deposed by the large company against whom she has brought suit. To any legal nurse consultant who has never witnessed a deposition, I highly recommend it. Of course, being neither the deponent nor the one taking the deposition, I was free to sit back and enjoy the show.

What was fun about this deposition? When you hear your observations quoted directly in a question to the deponent, it takes your analysis out of the world of paper and connects it to a real person. Even when you are sure of your work, you still hold your breath waiting to hear the reply you know should be forthcoming.

This deponent did not disappoint. She was an attorney representing herself, a choice I would not have made were I in her place. She was a master of obfuscation and passive aggression, managing to sound and seem concurrently ignorant, forgetful, and clever. I actually admired her a bit.

I would never have the temerity to repeat a phrase six times that I knew the opposing counsel did not want to hear.

I would certainly never have asked opposing counsel to hand tally my medical bills if he wanted the sum that badly.

I would not have set the “land turtle-speed” record for timely responses. No answer was given directly. No opportunity was missed to appear confused and uninformed. No reply was given in under two minutes.

That particular shade of red in opposing counsel’s face would have alarmed me to no end.

This was nothing like the many deposition transcripts I have read, with compliant claimants whose attorneys have told them to “stick to the facts” and answer as briefly as possible.

I could not stay for the whole deposition, which the attorney assured her would take the entire seven hours allowed by Georgia law, given her style of response. She blamed him for this. She refused to be photographed because she did not like the way she looked today. She offered a cell phone picture that was more flattering, but of course, the phone was dead and alas, no picture could be retrieved.

Yes, it was an eye-opening event. I cannot wait to do it again.

Here’s (Who’s) Looking at You, Kid

Legal nurses, like expert witnesses, attorneys and politicians, are only as credible as their public image. While we have faith in the integrity of our friends and fellow professionals, we are not immune to the intentional harm inflicted by others.

Most of us unwittingly sow the seeds of our own demise. We engage in light-hearted email bantering back and forth with friends and colleagues. We know to screen our Facebook friendships and confine our LinkedIn connections to business, but still…

We do love voicing an opinion when asked, and even when not asked.

Our professional listservs allow many opportunities to hone our critical thinking skills and play beat-the-buzzer at guessing elusive diagnoses, arcane abbreviations and other mind-teasers thrown out by our colleagues.

We might even voice a public opinion on an expert’s skill level. Woops.

What we say today will be here tomorrow, and the next day, and the year after that, forever circulating and percolating in cyberspace, molded into sound bites that hardly represent the original intent.

In fact, this recently happened to me, or rather, I did it to myself. I wrote a short article called “It’s not life… it’s social media” ( I still support most of what I wrote about not wanting a Facebook account, but I now have 160 Facebook friends, attend Martindale Hubbell online conferences, and recently presented a webinar on the use of LinkedIn. My disdainful article on social media lingers on.

Recently, a fellow LNC posted several sites that construct an image of you based upon your shopping habits, public profiles, emails, etc. The images were not accurate portrayals, but there are people who use their free time to make mischief for the rest of us.

As the NYPD day sergeant would say, “Let’s be careful out there” as we fall in love with the sound of our voices and the sight of our words.

Hold Nothing Back

I work with attorneys.  I know that they provide medical experts with selective records targeting their area of expertise.  Some of this is cost containment and some of it is shaping the view of the expert. This practice of selective omission and inclusion does not work for me as a legal nurse consultant. I want everything.  

An expert witness works within a narrow window and focuses upon rendering an informed opinion.  This expert is critically important, but how many will you need in a complex medical action? 

You only need one legal nurse consultant to work your medical case.

If that person is me, send me every scrap of data in your possession.  I am a bloodhound. If you omit information, I will know it.

In asking for the entire file, I have a targeted, cost-efficient yet comprehensive system for discovering critical information, discarding irrelevant data, and knowing what is missing.  My chronology clarifies the diagnostic picture and directs me to the authoritative research that will support my recommendations and conclusions.

The most relevant data is often the most elusive. That chicken scratch that passes for cursive writing may be at odds with the typed dictation. The casual comment to the ER nurse or EMS may not be admissible as testimony, but is no less relevant to the case.

In dealing with this abundance of information, I find the the pleading, affidavits, interrogatory and responses to be critical. These documents reveal the mindset of the claimant and the temerity of the attorney. I need that.

If  I am working a defense case, I know that an over-reaching complaint is an open invitation to investigating past medical care. Discrediting one specious charge will cast doubt on others. It is a rare individual who enjoys perfect health until an unwitnessed slip and fall in the drugstore.

If this is a plaintiff case, I am equally wary of the client who casts a wide net of complaints, or the nondisclosive client who selectively provides data.

In this world of healthcare litigation, we cannot truly function knowing this thing but not that thing.  The practice of picking and choosing data will come back to haunt both plaintiff and defense attorneys…particularly if the opposition has me on their team.