Archive for the ‘Catastrophic Wrongful Death’ Category

How Much is Your Marriage Worth?

Friday, June 10th, 2011

When you’re injured as a result of someone else’s negligence, it’s easy to see why you have a legal claim. You are entitled to recover for the injuries that you suffered, including economic damages (lost wages, medical bills, etc.) and non-economic damages (pain and suffering). However, if you’re married, there is another category of damages that you may be able to recover – damage to your marriage. It’s called Loss of Consortium and is an important element of damages in the right circumstances. It is a legal recognition that the marital relationship itself – separate and apart from the injury to the individual – is a protected interest that is deserving of compensation if it has been harmed by the negligence of another person.

Loss of consortium has an interesting history. Under Common Law (which roughly translates to “the olden days” in this circumstance) a woman had no right to sue for loss of consortium. It was only the man who had the right. That was because the woman was essentially seen as the man’s property. If she was injured and unable to provide her usual domestic or bedroom duties as a result of someone else’s negligence, the man could recover for the loss of such services. He had basically lost some of the value of his property so he was entitled to compensation. Eventually, the courts (most courts, at least) recognized the unfairness of such a one-sided system and ruled that women could also make such a claim if their husband suffered an injury. However, there are still some states (Virginia, for example) that do not recognize loss of consortium at all, no matter who tries to bring it.

Back to the present day. A loss of consortium claim arises when one spouse suffers a serious injury that impairs the marital relationship. An easy example is if a husband suffers a traumatic brain injury as a result of a doctor’s negligence. In that circumstance, the man would be able to file a claim for his own damages, of course, but he and his wife could also allege loss of consortium because the brain injury impacts the marriage. The couple will now find it more difficult to do the things they use to do together as man and wife – going out together, caring for their children, taking vacations, intimacy, and the day-to-day marital difficulties that arise because the husband now has a brain injury. In Maryland, a jury can award monetary damages for the couples’ loss of companionship, affection, assistance and yes, sexual relations. It is notoriously difficult to put a dollar figure on such injuries, but the law recognizes the right of a husband and wife to recover financially if their marriage has been damaged. How much money to award for such injury is for the jury to decide. Like other damages, it is always the plaintiffs’ burden to prove that the marriage has been injured, which is usually done through the testimony of the husband and wife.

Speaking of intimacy, some pundits say that loss of consortium is just a code-word for damage to the couples’ sex life. This is not entirely true as the marital relationship entails far more than just sex, but these pundits have a point. A loss of consortium claim usually does include an allegation that the couples’ sex life has been impacted. If you are bringing a lawsuit, you have to understand that when you allege loss of consortium, you are opening up the door on the most intimate parts of your life. Defense attorneys will often ask highly personal questions – how often did you have sex before the injury, how often do you have sex now, how exactly does the injury make sex more difficult, have either of you ever strayed from the marriage, etc. Some couples are understandably reluctant to discuss such things. Thankfully, most defense attorneys are just as uncomfortable asking these questions as the plaintiffs are answering them, so the questions tend to be over with relatively quickly. Be aware, though, that if you do file a loss of consortium claim, your sex life may become an issue in open court.

In the District of Columbia, a loss of consortium claim is for similar damages, but with a slight difference. While in Maryland the claim belongs to both the husband and the wife and is brought by them jointly, in the District of Columbia the claim belongs solely to the non-injured spouse. Any money awarded by the jury for loss of consortium goes to the non-injured spouse rather than to the couple jointly.

Lastly, Maryland’s cap on non-economic damages applies to claims for loss of consortium. There is no separate cap for this claim. In other words, there is a single cap that applies to all allegations of injuries, whether it’s an injury to the individual or an injury to the marriage.  The Maryland Legislature does not allow a couple to receive more money for injury to the marriage above and beyond the cap, even if a jury decides that that money should be given. Just another example of how Maryland’s cap punishes plaintiffs.

Have you ever suffered an injury that impacted your marriage? Did you file a loss of consortium claim? What was the result?

Related Nash and Associates Links

Maryland’s alleged healthcare “crisis”

Insurance and Traumatic Brain Injury

Acquired Brain Injuries

 

 

The death of a baby – the economic realities

Monday, June 6th, 2011

I recently wrote a blog about the grief that parents suffer when they lose an unborn child. At the risk of sounding crass, I want to now discuss the economics of lawsuits involving the death of an unborn child. For those contemplating taking legal action for the loss of their child, I hope this provides some useful information for you to consider.

Maryland courts have carved out specific rules for when an unborn child is considered a person capable of recovering damages in the event of death. The primary rule is that if a baby is actually born alive, no matter at what gestational age, that baby is considered a person with legal rights. So, if a 20-week baby is born alive and then dies one minute later, that baby is considered a “person,” and a lawsuit can be filed on behalf of the estate for that baby’s pain and suffering, otherwise known as a Survival Action.

(This leads to an interesting question – does a fetus feel pain? See Related Links below). The parents of the unborn child can also file what is known as a Wrongful Death action for their own economic and non-economic damages resulting from the death of their baby, primarily their grief and emotional loss over the death of their child. Survival actions and Wrongful Death actions are two separate claims, although they are usually pursued in the same lawsuit.

When a baby dies before birth, however, another question has to be asked: was the baby viable or not? Viability means that a baby is able to live outside the womb, even though he or she may require serious medical intervention. The current thinking is that babies are viable at around 22 weeks. The courts have made the rule that if an unborn child dies before the age of viability, that baby is not yet a “person” and has no legal rights. There can be no Survival Action and there can be no Wrongful Death action. If, however, the baby has reached the age of viability, then the baby is considered “a person” with legal rights, even if the baby was never born alive. Confusing? Yes it is.

The Maryland Courts were following the ruling in Roe v. Wade that a mother had a constitutional right to abort a non-viable baby. Therefore, a non-viable baby was not legally considered a person. If the baby was not a person, then no lawsuit could be filed on behalf of the estate of that baby, nor could the parents file a wrongful death action. So in order for a Survival Action or a Wrongful Death action to lie for an unborn baby, that baby has to have reached at least 22 weeks of gestation.

To make things even more confusing, the Maryland courts have carved out an exception to the above rules. Let’s consider the example of a non-viable baby (i.e., less than 22 weeks gestation) who dies before birth as a result of someone else’s negligence that injures the mother.

A common situation occurs when the mother (let’s say she’s 8 weeks pregnant) is injured in a car accident and suffers a miscarriage as a result. Looking at the above rules, one would think that no claim is allowed. However, the courts have said not so fast. In this circumstance, while the mother cannot recover for the grief of losing her child (because the child is non-viable and, therefore, not legally a person), she can recover for similar damages, including:

  • The depression, anguish, and grief caused by the termination of the pregnancy;
  • The manner in which the pregnancy was terminated;
  • Having to carry a baby which was killed by someone else’s tortious conduct; and
  • Having to witness the stillborn child or the fetal tissue that was to be her child.

I realize this itemization of damages sounds awfully close to the damages permitted in a Wrongful Death action – the very damages that are not allowed in the case of a non-viable baby. It is confusing, to say the least. The courts are trying to find a way to compensate a woman who is injured and loses her non-viable baby as a result of someone else’s negligence, while remaining true to prior precedent in this state that there is no Wrongful Death action allowed in the case of a non-viable baby.

Lastly, keep in mind that Maryland’s cap on non-economic damages applies to cases involving the death of an unborn baby. Economic damages (medical bills, lost wages) are usually very small in such cases. There are no lost wages because we’re talking about a baby, and the medical bills are usually small.

The value of these cases is in the emotional pain and suffering of the parents, and the physical pain and suffering of the baby (assuming a viable baby). Under Maryland law, the maximum allowable recovery for such a claim is $868,750 in a medical negligence action (assuming Mom and Dad both file a wrongful death action).

Under the hypothetical of the mother seeking recovery for the loss of a non-viable baby, the maximum allowable recovery is $695,000 if the allegation is medical negligence, and $755,000 if the allegation is non-medical negligence. (The Maryland Legislature has for some strange reason imposed different caps depending on whether the negligence is medical or non-medical, e.g., a car accident).

As for the question of whether an unborn child feels pain, please click on the link below for a blog by Brian Nash on this very issue.

Related Nash and Associates Links

Does a fetus feel pain

Hysteria over malpractice “crisis”

 

 

 

The Grief of Losing an Unborn Child

Wednesday, June 1st, 2011

Image from HopeforParents.org

Fetal Death In Utero. It sounds so clinical, so devoid of meaning. Maybe that is by design. Medical terms have a way of masking the real human suffering that is being described.

Adenocarcinoma instead of cancer. Cerebral hemorrhage instead of stroke…and “fetal death in utero” instead of “losing an unborn child.” The medical terms are necessary, but they don’t capture the essence of the diagnosis. As one woman told me, “I didn’t lose my fetus. I lost my baby.”

For any parent, the loss of a child is the most agonizing experience imaginable. As the father of two, I can’t even imagine being told that your child has died. I can’t imagine the life-long grief that follows. I almost decided not to write about this topic for that very reason – I didn’t know the pain of losing a child so who was I to write on it? But other times I’ve waded into topics despite a lack of personal involvement because the issue has touched those whom I care about. For example, I’m not a parent of a special needs child, but I’ve written on that topic because I am close to people who are raising special needs children. Their experiences deserve to be shared.  The same is true here.

For parents who have lost an unborn child, the sense of grief is no different than if the child had been born and then died. Unfortunately, our society seems less sympathetic to the loss because there is no infant that we have seen and gotten to know. We all recognize the agony of losing an older child. Even if we haven’t experienced it ourselves, we can at least try to understand how sickeningly awful it must be. We can then offer our support and love and condolences to those who have experienced it. With an unborn child, however, it’s different. We have a tendency to minimize the grief associated with losing an unborn child, as if the fact that the child wasn’t yet born makes him or her less real. Even medical providers are guilty of this. I’ve had women tell me that their doctors tend to treat miscarriage or stillbirth as a medical condition, not the loss of a loved one. For the parents of such children, however, the loss is deep and real and long-lasting.

Donnica Moore, M.D., an Ob/Gyn and the author of a book entitled “Women’s Health for Life,” summed it up well when interviewed by the New York Times:

Couples can feel there’s no socially accepted way to grieve. If you lose a family member, people know how to do that, they know how to support you and grieve with you. But this is new territory for a lot of us. It’s a tragedy for people who have gone through it that might not be on the radar of people who have not.

I’ve recently had the pleasure (strange word, I know, given the circumstances) of representing two wonderful families who lost children. One couple lost their 9-year-old son who died of a correctible heart condition that his pediatrician failed to detect, and the other couple lost their unborn daughter when the mother was 37 weeks pregnant after being sent home from the hospital where she had gone complaining of decreased fetal movement. It’s easy to see the grief for the first couple. One day they have a little boy going to school, playing, doing homework, and the next day he’s gone. With the second couple, it’s harder to see the grief, but it’s there. I’ll share their story briefly.

This was the first child for Michelle (not her real name) and her husband. They had already decorated the nursery and picked out a name. One evening (believe it or not, Michelle had just attended a baby shower earlier in the day) she felt that the baby wasn’t moving as much as usual and called her doctor’s office. They told her to go to the hospital, which she did. At the hospital, she and her baby were evaluated and told that everything was OK. She was told to go home and keep her regularly scheduled appointment the next day. When she went to her doctor the next morning, however, the doctor could not find a heartbeat. Her daughter, unfortunately, was gone. To make things even worse, Michelle then had to carry her deceased daughter inside her for another full day before she gave birth.

Michelle did her best to move on with her life. She continued to work. She and her husband had another child. But for the entire time I represented her (to its credit, the hospital approached us about resolving the case early on) there was not a single time I talked to her that she did not start to cry in discussing her first baby – the daughter who should now be three years old. She still grieves for the loss of her daughter, wonders why it happened, wonders what her daughter went through in those final moments. She asks herself whether she did anything wrong, whether she should have been more forceful that night in the hospital. These questions don’t go away for her. They’re the same questions that any mother would ask after losing her child – whether it was an unborn child or an older child.

We all need to do a better job of recognizing that the pain of losing an unborn child – whether by miscarriage or stillbirth – is deep and long-lasting. If you know someone who has lost an unborn child, don’t shy away from him or her. A simple and genuine “I’m sorry for your loss” is a good starter. Be there to offer support and talk just like you would if the child were older. Don’t expect it to go away in a matter of weeks, and don’t assume that a subsequent pregnancy somehow erases the pain of losing the previous child; it doesn’t. Also, try to avoid clichés, e.g., “everything happens for a reason,” “I’m sure you’ll be able to have more kids.” While such sayings are meant well, clichés tend to minimize the degree of loss. If you don’t know what to say, it’s perfectly fine to say, “I don’t know what to say.”

If you yourself have lost an unborn child, you need to treat this loss like you would the death of a loved one. It is a long, slow, painful process that not everyone will fully understand. That can add to the sense of loss because you may get the feeling that people are expecting you to be over it already. Don’t let their artificial time-tables dictate your own personal grieving. You may also experience feelings of guilt, asking yourself if you did something during your pregnancy that caused this (in almost every case, the answer to that question is a resounding no). You may feel resentful toward other parents or children, or find it difficult to be around children, especially those who are the same age as your child would be. You may wonder if you will be able to have another baby. All of these feelings are completely normal, but they will take time to resolve.

Additional Links

Here are some good links to learn more about the grieving process for unborn children.

National Share

AmericanPregnancy.org

Related Nash and Associates Links

Pregnancy-related gingivitis and prematurity

 

 

 

Robot Anesthesiologists?

Tuesday, April 19th, 2011

robotic intubationFor anyone contemplating serious surgery, it can be a scary endeavor. From going through it myself and talking to others, I know that the main fear we have going into it is that the surgeon will make a mistake during the surgery, or that we will develop serious complications such as a hematoma, infection, etc. that leads to death or paralysis. While these are very real risks of many forms of surgery, there is another aspect of surgical procedures that gets less attention from patients – the anesthesiologist. While it may get little notice from patients, anesthesiology is a highly complex field of medicine in which doctors (and certified nurse anesthetists) train for years to be able to do it well. This post will focus on just one aspect of anesthesiology known as intubation, and a new development in robotics that may improve the procedure.

What is intubation?

At its most basic, intubation is the process by which the anesthesiologist places a thin plastic tube into the patient’s windpipe to maintain an airway or to facilitate mechanical ventilation. While this is done in a variety of serious medical situations, it is almost always done during major surgery when the patient is under general anesthesia. During such surgery, the patient is rendered unconscious and is unable to breathe on his or her own. Therefore, the anesthesiologist has to essentially breathe for the patient during the surgery, either using a ventilator or sometimes compressing a bag that replaces natural breathing. The process of intubation allows this artificial breathing to take place. Because intubation itself is a painful procedure (remember – a tube is being inserted far down your throat), the patient is usually given paralytic drugs (drugs to induce paralysis) before intubation. This is a key point we’ll come back to later.

Risks of Intubation

While it may sound as simple as sliding a tube down the throat, intubation carries its own risks separate and apart from the risks of anesthesia itself (risks from anesthesia can include death, paralysis, brain damage and a whole host of other less serious injuries). With intubation, there are minor risks such as chipped teeth, lacerations in the gums and sore throat. However, there are many more serious risks as well, including perforation of the trachea, mistakenly placing the tube down the esophagus (a more common occurrence than you might think), aspiration of stomach contents, vocal cord injury, decreased oxygen and elevated carbon dioxide, and nerve injury. Intubation is a serious procedure that requires a high degree of skill and training to do it well and safely.

What if the tube does not get placed properly?

Inability to secure the airway is a major problem in intubation. To understand why, you have to remember that before the tube is placed, the anesthesiologist paralyzes you with drugs. Therefore, before the tube is placed, you stop breathing on your own. It is then critical that the tube be placed quickly and accurately to ensure that you don’t suffer from a lack of oxygen (or ventilation – the exchange of oxygen and carbon dioxide). So what happens when the anesthesiologist has trouble getting the tube in? It just so happens that I have some personal familiarity with that scenario.

A few years ago I had back surgery. The surgery itself was not complex as far as spine surgeries go (it always amazes me how surgeons are able to describe cutting open your back and operating on your spine as casually as they might describe changing a light bulb). It essentially consisted of trimming off a small piece of disc that was pressing on my spinal cord and causing pain to radiate down into my leg and foot.  I was in and out of the hospital the same day, but of course I was under general anesthesia so I had to spend a couple of hours in the Post Anesthesia Recovery Room (PACU) to make sure that I was not suffering from any ill effects of the anesthesia. While waking up, and still groggy, the anesthesiologist walked up to me and said, “I just want to let you know – you were really hard to intubate. If you ever have surgery again, be sure to tell your doctor that you’re really hard to intubate.”

I asked the doctor what he meant by that. He told me that because of the anatomy of my mouth and throat, he had had a really difficult time getting the tube into my airway. Keep in mind, the tube was placed down my throat after I was given drugs to paralyze me. Even in my post-anesthesia addled state, I knew enough to ask the obvious question – what would have happened if he couldn’t have gotten the tube down in time? He was casual in his response. “Oh, we would have given you drugs to wake you back up.” How comforting. My next thought was, “Maybe you could have checked my anatomy out before you gave me paralyzing drugs.” I didn’t ask that because I am sure they did check me pre-operatively.  That is standard procedure before giving anesthesia to make sure that the anesthesiologist knows the patient’s anatomy and can anticipate problems. Apparently, my anatomy was a little more vexing than he had bargained for. However, he was finally able to get the tube in and the surgery went well.

The use of robotics

Because of the ever-present risk of serious complications, researchers are always working on improving intubation to minimize risk. It has always been a hands-on procedure that depended on the skill of the individual performing it. Now we may be moving into a whole new world of intubation thanks to advances in robotics.

Medical News Today is reporting that Dr. Thomas Hemmerling of McGill University and his team have developed a robotic system for intubation that can be operated via remote control. According to Dr. Hemmerling:

The [device] allows us to operate a robotically mounted video-laryngoscope using a joystick from a remote workstation. This robotic system enables the anesthesiologist to insert an endotracheal tube safely into the patient’s trachea with precision.

The system is still in development. It has been widely tested with mannequins that mimic human anatomy, and clinical testing on patients has now begun. Dr. Hemmerling hopes that the new device will allow anesthesiologists to intubate patients using less force and higher precision, which should help to improve patient safety. Even with the use of robotics, I would think that intubation, including pre-operative assessment of individual anatomy, is going to require close hands-on involvement in order to ensure that it is done safely and properly, but it is always exciting to see what was once science fiction being used in real-life surgeries.

What you can do

While robotic anesthesiology is still down the road for most of us, there are still things you can do to minimize your risk of injury. Before agreeing to surgery, most of us do a good job of vetting our surgeon – how experienced he or she is, how many similar procedures he or she has performed. How many times have you heard a friend describe his or her surgeon as “the best?” Yet virtually no one who has been a patient – at least in my experience – makes any inquiry into the experience level of the anesthesiologist, even though a mistake by this person can render you paralyzed or brain-dead (or even dead) in a matter of minutes.

If you are planning on undergoing serious surgery, I would encourage you to discuss the anesthesia care with your surgeon. Find out ahead of time who your anesthesiologist is going to be (if that’s possible), and discuss your situation with that person. No doubt you will be evaluated by the anesthesiology team before your surgery, but it may well be the same day as your surgery, and it will feel like just another routine matter like signing a few forms. Keep in mind, however, that anesthesiology is just as important as the surgery itself. Stay informed and ask questions. Treat your pre-operative session with the anesthesiologist as if your life and health were depending on it – it just may!

And as for robotics, I’m curious what your comfort level would be if your doctor suggested using a robot to intubate you? Would you be willing to try the procedure, or would you prefer the traditional hands-on, human approach?

Image from “Today’s Medical Developments”

Aneurysms – A Potentially Deadly Condition That May Present as Back Pain

Monday, April 18th, 2011

I have been writing a series of blogs devoted to common and not-so-common causes of back pain, some of which cause devastating and catastrophic injury.  Aneurysms of the aorta, either in the chest or abdominal cavity, can present as back pain, and these can often be fatal if not diagnosed or treated in a short period of time.

Considering that 1 in every 50 males over the age of 55 have an abdominal aneurysm, this is a more common pathologic diagnosis than some others.  Men also corner the market at an 8-to-1 ratio as compared to women with abdominal aneurysms. Thoracic aneurysms make up only 10% of the total number of aneurysms of the aorta, but these have a much poorer prognosis.

What is an aneurysm?

An aneurysm is a localized dilatation (i.e. the widening or stretching of an opening or a hollow structure in the body) of a blood vessel or even the heart, itself, due to some induced weakness in the wall of the vessel. The aorta is the largest blood vessel leaving the heart and transporting blood, oxygen and nutrition to every cell in the human body. It has the highest pressures and the thickest walls.

Should the weakness in the wall of the vessel rupture, blood will be released in such quantities and at such high pressures that the rapid blood loss causes a rapid death in most patients. There are a few exceptions, depending on which side of the blood vessel ruptures. If the rupture occurs on the side facing the abdominal cavity, the blood loss tends to be rapid since no opposing structures obstruct the flow. If the rupture occurs on the side facing the spinal column, structures in the near vicinity can actually slow the flow of blood allowing for a small time frame for diagnosis and intervention to occur. Sometimes, there is a slow “leak” of blood prior to a massive rupture, and this blood causes irritation and pain, allowing for a “window-of-opportunity” for a diagnosis to be made and intervention to occur.

I’ve provided a link at the end of this article to a well done video explaining aneurysms.

Real Case Scenario:

Patient M was a 62-year-old, moderately obese female, who came to the ER when I was working one day, complained of some vague low back pain and several episodes where she briefly lost consciousness that morning while trying to get up and move around. No injuries were sustained, but she felt very weak and light-headed. Her blood pressure was 109/68 while lying flat with a heart rate of 96. An attempt was made to obtain a blood pressure while sitting, but Patient M became near-syncopal and sweaty. A quick examination of her abdomen revealed a pulsatile aneurysm in her abdomen measuring 6cm (almost 2 1/2 inches wide). I was able to contact the vascular surgeon, have nurses place appropriate IV lines and obtain labs, and I notified the nursing supervisor regarding the need for an operating room. Patient M actually went for a CT scan on her way to the OR; the CT verified a “leaking” abdominal aortic aneurysm. Patient M was in the OR within 20 minutes of my evaluation. Upon opening the abdomen, the bleeding worsened, but the surgical team was prepared. They did have to resuscitate Patient M once, but a repair of the aorta was effective, and she went home within one week of her life-saving operation!

How is an aortic aneurysm diagnosed?

Most are actually diagnosed incidentally when patients undergo various diagnostic studies for other, unrelated complaints.These are the luckiest patients, because aneurysms can be detected early, monitored and then the patient can be offered elective intervention before an acute rupture occurs. It seems that 5cm (about 2 inches) is the “magic number” when it comes to an indication for repair since an aneurysm larger than that significantly increases the risk of rupture. Now, with endovascular (i.e. procedures in which a catheter is placed inside the blood vessel) repair options (“stenting procedures”), some of these aneurysm repairs can be done in a minimally invasive manner, offered even earlier, and have very good outcomes with only 2-to-3 day hospital stays.

Routine but thorough physical exams by a conscientious practitioner can ofter detect aneurysms in the abdomen simply by feeling the abdomen by hand. The chest cavity is more difficult for obvious reasons. Chest x-rays can sometimes suggest a problem if calcifications are present in the vessel wall (high-lighting the vessel contour) or if abnormalities are detected in the mid-line structures that overlap in this 2-dimensional picture. These patients can then undergo subsequent imaging studies to determine the existence and extent of the aneurysm.

When aneurysms go undetected, the acute presentation can also vary depending on the location of the aneurysm both in relation to the distance from the heart and the side of the vessel. Because of the position of the aorta anatomically (close to the spine), patients often experience back pain due to impingement of the spine and spinal nerves. If the aneurysm is in the chest cavity (thoracic), one often will feel upper to mid-back pain that can range from dull and aching to searing and excruciating; this may or may not accompany chest pain and other symptoms. If the aneurysm is in the abdomen (most often below the arteries that supply the kidneys), a patient will often complain of low back pain that could extend into the groin, and again, this pain can be dull and aching or sharp and excruciating.

What causes aortic aneurysms to occur?

The most common cause of aortic aneurysms is atherosclerotic vascular disease, commonly called cholesterol-plaqueing of the arteries. There are a multitude of other causes such as genetic conditions, fungal infections, bacterial infections, and other collagen-vascular diseases. Those individuals who have abnormal cholesterol panels, high blood pressure, perhaps a history of coronary artery disease or peripheral vascular disease, and diabetes are at risk for aortic aneurysms as they age.

Bottom line?

So, a person who is a little older with perhaps some of these notable risk factors who develops unusual back pain with no apparent precipitating cause (excessive physical activity/labor, fall, etc.) should be evaluated for a possible aneurysm. If present and detected, it is often a treatable condition; left untreated, it will ultimately lead to death, which is often sudden. Medical technology even offers minimally invasive procedures that are quite effective if treated early enough and located in an accessible region. Keep in mind that thoracic aneuryms do have a worse prognosis than abdominal aneurysms.

Here’s the link to the video explaining aneurysms.

Image from aorticstents.com

Week in Review: Miss our posts this past week? Catch-up now!

Saturday, April 16th, 2011

From Eye Opener’s Editor, Brian Nash: Another week gone by – where does the time go? Our bloggers this past week, Theresa Neumann, Jon Stefanuca, Jason Penn, Mike Sanders and Sarah Keogh, were – in addition to practicing law – busy on the keyboard blogging away. In case you missed any posts during the week of April 10th through the 15th, here’s your opportunity to catch-up.

The “Medical Home” – find out what it is and why you should have one!

This past week, Sarah wrote two blogs on a concept that frankly I had not heard of before – the Medical Home. Her follow-up piece on how parents in particular are using emergency departments and clinics was posted yesterday, Friday, April 15th.

In her first piece, Sarah discussed a key issue about continuity of medical care for all of us but particularly our children. While there’s no doubt that there are times when taking your child to an emergency room is the only way to go in a true emergency, is it really the right place for a child to receive primary care? You see a physician or a medical specialist such as a physician’s assistant on a one-time basis. What do they really know about your child’s complete medical history? Do they really address key issues of general health care that is essential to your child’s overall health?

Her second post addresses specifically the topic of how many in this country are using facilities such as in-store clinics and emergency rooms for minor, non-emergency care. While there is no doubt that ED’s and clinics serve a vital role in the providing of healthcare in the United States, are they being used the right way? Are clinics often the only place where many in our country can obtain care for their children? Read Sarah’s posts on What is a medical home? Do your children have one? and her follow-up piece Clinics and Emergency Rooms: Helpful or Barriers to Good Pediatric Care.

A Disturbing Report on Some Area Hospitals and their Complication Rates

Earlier in the week, the new member of our legal team, Jason Penn, wrote about a recent report from the Maryland Health Services Cost Review Commission regarding a continuing failure of several local Maryland and DC hospitals to lessen the number of patients who suffer from complications while in these institutions. P.G. Hospital Center won the dubious distinction of being first in class. Jason reports that this institution, which services many of the area’s population, was fined by the state of Maryland for the number of “complications that are unlikely to be a consequence of the natural progression of an underlying disease.” The “list” includes specified complications such as “bed sores, infections, accidental punctures or cuts during medical procedures, strokes, falls, delivery with placental complications, obstetrical hemorrhage without transfusion, septicemia, collapsed lungs and kidney failure.” For information as to how the local jurisdictions deal with these hospitals in the pocketbook and who made the list, read Jason’s blog post entitled Report Card on Failing Hospitals: Prince George’s Hospital Center Tops “Complications” List.

Learn More about Medicine and Your Health

Theresa Neumann, an in-house medical specialist in our firm, posted Spinal Stroke: An atypical cause of back pain this past week. It’s one thing to have lawyers who live and breath medicine and the law write about medical conditions; it’s quite another to have real medical specialists like Theresa educate all of us on medical matters that affect the lives of so many. Theresa brings to the public’s awareness the signs, symptoms, risks and potential treatment alternatives to a catastrophically disabling condition that many just don’t know about – until it’s too late for them.

We’ve all – unfortunately – heard about or know someone who has suffered a stroke in their brain. Well, as Theresa reports, there’s an equally devastating form of stroke that can hit our spinal cord, which can render the victim paralyzed, without control of bowel or bladder, incapable of feeling sensation and a host of other life-altering consequences. We’re always appreciative of the wonderful, educational pieces Theresa brings to our blog. This piece is no exception.

The War against Super Bugs – MRSA and CRKP – are we losing the fight?

There was a time many months ago where we all became aware of the super bug infection known as MRSA. It was in the news over and over again. Have you heard much about it lately? Silence by news media might make one think that our medical institutions have won the war and the threat of this deadly infection is over. As Mike Sanders tells us – not so quick! In his blog of this past week, Deadly Super Bugs on the rise, Mike tells us who’s winning the MRSA war to and about a newcomer in the Super Bug family – CRKP.

The news is simply not good! See what seems to be working against MRSA and don’t miss the update at the end of Mike’s post about a new prevention method using honey.

Law and Medicine

Well we are lawyers – so why not a piece about our specialty area – representing patients and families of patients against healthcare providers? This past week, Jon Stefanuca wrote what we consider to be a very important piece entitled Should you sue a healthcare provider? Some guidelines to help you decide.

Some may just be surprised about the advice Jon gives in this posting. It is not a call to arms against the medical profession or even a call to our law firm so you can sue the b*****ds! Jon offers some very important advice to those who have been through an experience with a healthcare provider and are considering whether or not they have a potential lawsuit for the injuries they have suffered.

We believe this post encapsulates in large part some principles we have been advocating for a long time. Not every bad outcome means malpractice has occurred. However, how would you – as a lay person – be able to make the distinction between what is and what is not a real medical malpractice case? In addition to Jon’s sage advice, this post links to a White Paper we did on Choosing a Lawyer – a Primer. We hope if you have unfortunately found yourself faced with this issue of whether you should sue or not that you will find this blog by Jon informative and helpful in making your decision.

A Sneak Peak of the Week Ahead

As you can see, our bloggers were quite busy last week. Well, this coming week will be no different. The days ahead will be consumed with representing our clients in depositions, investigations, filing pleadings and court appearances….and writing and posting some interesting, important blogs on aneurysms (did you know they can present as back pain?), laughing gas coming back for moms in labor, sleep deprivation for nurses (and how well that plays out in your healthcare) and some other good stuff our writers are busy working on this weekend and during the week ahead.

Stay tuned – stay informed! Read the Eye Opener and tell your friends about us too! …and don’t forget to join our social networking communities on Facebook and Twitter.

Deadly Super Bugs on the rise.

Wednesday, April 13th, 2011

Health scares are common and are many times overblown. However, the evolution of bacteria that are resistant to antibiotics (dubbed Super Bugs) is a very real and growing danger. Yahoo Health is reporting that two especially dangerous bacteria – MRSA and CRKP – are becoming resistant to all but the most advanced antibiotics, which is posing a major health threat.

Klebsiella is a common type of gram-negative bacteria that are found in our intestines (where the bugs don’t cause disease). MRSA (methacillin-resistant staphylococcus aureus) is a type of bacteria that live on the skin and can burrow deep into the body if someone has cuts or wounds, including those from surgery.

The reason for this new resistance is likely over-use (which includes mis-use) of antibiotics by health care providers (with likely some contribution from use of antibiotics in animals). For a few years now, there has been a growing recognition that doctors are over-prescribing antibiotics, i.e., routinely prescribing antibiotics when they are not necessary. For example, in 2005, U.S. News reported a Harvard study that revealed that doctors routinely prescribed antibiotics for sore throats in children when they were not indicated. A 2007 study indicated that Dutch doctors (whom are generally considered more careful in their use of antibiotics) routinely prescribed antibiotics for respiratory tract infections when they were not indicated.

The Problem with “Overuse”

The danger this poses is that antibiotics – even effective ones – typically leave some bacteria alive. These tend to be the stronger or more resistant bacteria, which then leads to the development of more and more resistance. This occurs in a single individual body in which a patient may have less response to an antibiotic after earlier use of that same antibiotic, but because of the easy spread of bacteria in our world, it also occurs on a global scale. For certain strains of bacteria, doctors are becoming hard-pressed to treat these infections.

CRKP – worse than MRSA?

Thankfully, MRSA is still responsive to several antibiotics so it is still considered a treatable infection. CRKP, however, is of more concern because it is only responsive to Colistin, which can be toxic to the kidneys. Therefore, doctors have no good options when treating CRKP. While so far, the risk of healthy people dying from MRSA and CRKP remains very low, the most vulnerable of us (the elderly and the chronically ill) remain at risk because of their lowered immune system and because the elderly are in nursing homes or other long-term care facilities where infections tend to spread more easily than in the general community.

CRKP has now been reported in 36 US states—and health officials suspect that it may also be triggering infections in the other 14 states where reporting isn’t required. High rates have been found in long-term care facilities in Los Angeles County, where the superbug was previously believed to be rare, according to a study presented earlier this month.

It is essential that we rein in the casual use of antibiotics before we are left with infections that have no cure. Doctors must be better trained to know when antibiotics are necessary and when they are not. For example, antibiotics are useless against viruses (such as the common cold), but how many of you have been given an antibiotic by a doctor “just in case” or because your symptoms have gone on slightly longer than a typical cold would last? It is unfortunately a more common occurrence than we realize. The past success of antibiotics has naturally led doctors to want to give them to patients to relieve suffering. No one wants to turn down a patient who is seeking relief.  However, it makes no sense to give antibiotics to a patient who has no bacterial infection or whose illness will clear up on its own.

Patient Awareness is key

The problem, however, is more than just educating doctors. Patients share some blame too. We – the public – need to learn that antibiotics are not always needed, which can be a difficult lesson to learn when we’re sick. Everyone knows that antibiotics are a quick and effective remedy against common bacterial infections. Antibiotics have saved countless lives over the years and have relieved untold human suffering. So naturally, when we are sick (or our child is sick) and we go to the doctor, we want to see results. We want something that will alleviate the pain and symptoms, not simply be told to wait for the illness to run its course. Sometimes, however, that is the best course when you consider the side-effects of antibiotics and the dangers of over-use. That being said, who wants to hear that when you’re in pain and want relief? It is very easy to demand of doctors that they use all available means to treat a sick child. Doctors need to be able to stand-up to patients and educate them on why antibiotics are not necessarily the best course of treatment in a specific situation.

Don’t kill the good ones!

Doctors also have to teach patients that antibiotics are not targeted killers.  The body contains a lot of good bacteria that are vital to our body’s functioning.  Antibiotics kill those bacteria as well, which some researchers believe can adversely affect health by allowing harmful bacteria to proliferate.  (If you have seen “probiotocs” advertised on certain food products – like yogurt – that is an attempt to introduce good bacteria back into your body.).

Some basic steps to take

In order to protect yourself (or a loved one), good hygiene remains the most effective method of remaining infection-free.  Thankfully, neither MRSA or CRKP are transmitted through the air.  They are typically transmitted through person-to-person contact, or else through hospital equipment such as IV lines, catheters, or ventilators.  If you have a loved one in a hospital or nursing home, be vigilant with your hand-washing and those of the healthcare providers caring for your loved one.

Also, if you are a patient who has been prescribed antibiotics, follow your pharmacist’s orders scrupulously and take the medication in the proper dosage and for the proper amount of time.  Stopping antibiotics too soon can leave bacteria alive, which contributes to the evolution of more resistant bacteria.  You may feel better and want to stop the medication, but it is important to take the full dose.

So – now that you know the risks of over-using antibiotics, are you willing to forego antibiotics when you are sick in order to do your part for the greater good?

UPDATE: (Editor – Brian Nash) Within an hour of posting Mike Sander’s blog on MRSA (and CRKP), I came across a tweet about Manuka Honey is being used for dressings to fight the spread of Super Bugs – particularly MRSA.

Researchers now believe that it can also put a stop to the rates at which superbugs are becoming resistant to antibiotics.

Anyone know of this practice being used in your area hospital or clinics? Does anyone know if this really works? If so, most interesting and useful. Here to spread the word – how about you spreading it too?

Why do so many patients die when their in-hospital alarms go unheard or unheeded?

Thursday, February 17th, 2011

ICU alarm monitor

Sunday’s edition (February 13, 2011) of the the Boston Globe online (boston.com) tells a chilling story of how many times the alarms used to monitor patients go unheard and unheeded by medical staff leading to death or catastrophic injuries for patients throughout this country. The story, which was a two part series (for the second installment, see For nurses, it’s a constant dash to respond to alarms) by Globe reporter Liz Kowalczyk, narrates numerous incidents in which alarms simply went unnoticed, ignored or unmonitored. Numerous other issues such as lack of education of hospital staff as to how to properly connect the devices, failures to realize the batteries had gone dead, turning the alarms so low in volume they could not be heard, taping over amplification systems to avoid the “annoyance” of the alarms and the like are also chronicled in this series. While it is documented by an analysis of the FDA’s database of adverse events involving medical devices that 216 patients died nationwide between 2005 and mid-2010, it is also certain that this number of alarm-related deaths is probably much higher. The ECRI Institute, which was hired by the Globe to analyze the FDA database, believes that the health care industry under-reports these cases to the FDA.

Some examples of alarm-related deaths

Since links to the Globe’s original articles are provided above, I will not go into the level of detail that is otherwise available through reading the original reports. Here is a sampling of the types of “alarm failures” leading to patient deaths:

  • staff misprogrammed complicated monitors
  • staff had forgotten to turn the monitors on
  • batteries had gone dead leading and failed to function (one instance where a man had a “flat line” for more than two hours that went undetected)
  • defective wires or connections on the monitors
  • malfunction or design flaws in the monitoring devices
  • staff ignored the device warnings because of “alarm fatigure

Alarm Fatigue

According to one computation at Johns Hopkins Hospital in one 15 bed unit as to how often alarms go off during the course of day, it was documented that there were 942 alarms per day – “about 1 critical alarm every 90 seconds.” There is no doubt that the number of alarms and the clinical settings in which they are used have increased over the years. As Ms. Kowalczyk noted, “[W]ith the use of monitors rising, their beeps can become so relentless, and false alarms so numerous, that nurses can become desensitized – sometimes leaving patients to die without anyone rushing to their bedside.”

In some cases, busy nurses have not heard or ignored alarms warning of failing batteries or other problems not considered life-threatening. But even the highest-level crisis alarms, which are typically faster and higher-pitched, can go unheeded. At one undisclosed US hospital last year, manufacturer Philips Healthcare, based in Andover, found that one of its cardiac monitors blared at least 19 dangerous-arrhythmia alarms over nearly two hours but that staff, for unexplained reasons, temporarily silenced them at the central nursing station without “providing therapy warranted for this patient.’’ The patient died, according to Philips’s report to federal officials.

Keep in mind that many of these alarms are not only audible in the patient rooms; they also sound at the central nurse’s station. In some instances, hospitals have put up hallway speakers for nurses to hear the alarms more readily. In other facilities, in addition to audible alarms, various pieces of critical data information (e.g. heart rhythm, heart rate) are visible on displays at nurses stations and in some places, it is reported, “on brightly colored scrolling signs in corridors.”

The article quotes one nurse at Boston Medical Center, who addresses some of the issues at the heart of this “alarm fatigue” phenomenon.

Everyone who walks through the door gets a monitor. We have 17 [types of alarms that can go off at any time. They all have different pitches and different sounds. You hear alarms all the time. It becomes...background

False Alarms - the cry wolf issue

It is well known that some alarms can go off when a patient sits up, coughs, turns or makes other normal movements. According to the Globe report, "'[s]ome studies have found that more than 85 percent of the alarms are false.” I have no idea how this statistic was compiled, but even if it is accurate (which is debatable), that still leaves dozens if not hundreds (if not thousands) of alarms going off daily in every hospital throughout this country that are an indication of a patient in need of rapid response life-saving care.

Another nurse is quoted by the Globe in expressing both the frustration and the need for attentiveness when the alarm goes off. “You have to respond to the alarm[, b]ut there are some days when you feel you’re just running from alarm to alarm. It can be exasperating.”

The Fix

The short answer appears to be: there is no easy, quick fix. Here are some of the measures institutions have taken to address this problem:

  • working with engineers at prestigious institutions (e.g. MIT’s work with Boston’s Children’s Hospital) to develop more sophisticated monitors to identify true crisis alarms.
  • hiring of dedicated monitor technicians and/or nurses, who man the central nurses’ station to triage alarms.
  • specialized education programs to avoid misprogramming or connection mistakes due to lack of knowledge by staff
  • establishing tighter standards of which patients should be connected to alarmed monitors – to cut down on the “background noise” of alarms.
  • replacement of old equipment for more advanced, accurate alarm/monitor systems
  • implementation of new programs in-hospital to require bioengineers to check the monitors daily to make sure they are working properly.
  • implementation of standardized settings on machines so that alarms are not turned so low they are non longer audible. (One case of a patient death was attributed to staff turning the the “vexatious” alarm down to a 40% of full volume – no one responded to an arrhythmia alarm for 40 minutes because no one heard the reduced volume alarm during that time.)
  • changing batteries every day in monitors to make sure they are, in fact, charged and working

The Blame Game

As you might suspect, the finger-pointing that takes place after a patient is found dead or severely injured is rampant. As the Globe reports, “Initially, hospitals almost always blame the monitor’s alarm for not sounding when it should have, according to reports. But the company investigations show the assertion is often false.”

In 40 of the cases reviewed by the Globe, the alarms did not sound, usually because the staff had not properly programmed or turned on the machines.; in only eight cases was there a malfunction or design flaw.

[I]n nearly 100 cases, manufacturers ere unable to determine exactly what went wrong, often because they didn’t have enough information, or they told federal regulators they still were reviewing the death.

Where to from here?

While I certainly don’t have to contend with the incessant noise of alarms going off all day long, nor am I required to jump away from what I’m doing to respond to a false alarm, I can’t help but think that in a health industry as advanced as ours allegedly is, there must be some steps that can readily be taken so that others don’t die because some nurse has “alarm fatigue,” or a battery died, or the volume was turned down too low to avoid the annoyance of the alarm or some other ill-conceived and unacceptable reason.

What suggestions do you have for the healthcare industry to deal with this problem? Have you ever worked in a setting where this is a problem? If so, how did you and/or your institution deal with this issue? There are a lot of smart people in bioengineering and in our health institutions; why is this still such a problem in a country that claims to be so advanced?

Image by ectopicinteractive.com

A Surgeon’s Sleep Deprivation and Elective Surgery – Not a good (or safe) combination

Friday, January 14th, 2011

The New England Journal of Medicine published a Perspective on December 30, 2010, that screams common sense and should be embraced as a starting point to implement some new patient-safety standards of practice.

Place yourself in the position of a patient getting ready to undergo an elective (i.e. non-emergency) surgical procedure. You’re wheeled into the operating room for your surgery and are greeted by your surgeon in the process. Your mind is focused on just coming out alive and better than when you went in. What you don’t know, however, is your surgeon has been up all night handling a busy call schedule. If you knew he/she was dead tired as any human being would be under the circumstances, would you really want this surgeon operating on you? If you don’t care, then this post is really of no interest to you. If you do care, then read on.

Well, you’re still reading…so you must have some level of concern for your safety. Good for you because here’s a startling number in terms of adverse incidents when involving sleep deprived surgeons:

Researchers have documented the adverse effects of sleep deprivation and sleep disorders on individual performance. In surgery, there is an 83% increase in the risk of complications (e.g., massive hemorrhage, organ injury, or wound failure) in patients who undergo elective daytime surgical procedures performed by attending surgeons who had less than a 6-hour opportunity for sleep between procedures during a previous on-call night.

Note that this relates to elective surgery – you elected to have it; it is not an emergency. Sure, if the surgery has to be rescheduled, that’s a major inconvenience and not emotionally satisfying after you have prepared yourself for the “magic hour” when you are to be taken to the operating room. In most surgeries, you have not been allowed to eat since midnight (NPO status) if you are going to be anesthetized during your surgery. But let me ask – would you rather be inconvenienced or suffer from “a massive hemorrhage, organ injury, or wound failure” – to name but a few of the things that could go wrong at the hands of a sleep deprived surgeon?

The NEJM article reports that “most patients would be concerned about their safety if they knew their doctor had been awake for the prior 24 hours.” I really don’t think they needed a survey to reach that conclusion. Do you?

So how is this risky situation supposed to be avoided? Are you supposed to ask your surgeon: “So did you get a good night’s sleep?” Or – “How you feeling today, Doc? Well rested?” While some more assertive patients might take this approach, way too many, I’m afraid, would just “trust” their doctor to know  better than to operate under such a condition and advise the patient now is not a good time for him/her to do the surgery. In an ideal world, that’s what should happen – but we don’t inhabit such a world now do we? For whatever motivation – some good; some not so good, I sincerely doubt this is going to happen and certainly should not be the standard. In fact, the following excerpt from the NEJM piece addresses this very issue – at least in part:

Chronic sleep deprivation degrades one’s ability to recognize the impairments induced by sleep loss.5 Sleep-deprived clinicians are therefore not likely to assess accurately the risks posed when they perform procedures in such a state, and they should not be permitted to decide whether or not to proceed with elective surgery without obtaining the patient’s informed consent.

That’s a start, but frankly, I’m not really a big advocate of this approach. Obtaining my informed consent? So what happens – I’m told as I’m awaiting my surgery that my doctor has been up all night and the prior day. He then asks, “Are you willing to have your surgery anyway?” I then ask: “Well how are you feeling? Are you up to doing this?” If I get an affirmative response, why should the burden be on me (read: YOU in this scenario) to make a decision if it’s alright to proceed?

I much prefer the primary suggestion of the authors:

As a first step, we recommend that institutions implement policies to minimize the likelihood of sleep deprivation before a clinician performs elective surgery and to facilitate priority rescheduling of elective procedures when a clinician is sleep-deprived. In addition, patients should be empowered to inquire about the amount of sleep their clinicians have had the night before such procedures.

While I say I “prefer” this approach of “implementing policies to minimize the likelihood of sleep deprivation,” I would modify this “recommendation” to read – “to implement policies to eradicate the likelihood of sleep deprivation or in those instances where certain “sleep guidelines” have not been met, to mandate the rescheduling of this elective surgery. Note that the latter part of this “first step” recommendation puts the burden back on the patient “to inquire about the amount of sleep their clinicians have had the night before such procedures.” Same issues; same problems. The patient should not be put in this position. The hospitals ought to be protecting the patient in such situations, not empowering them – whatever that means!

This is a problem whose solution is not that complex. It is a problem whose solution is way too long overdue. I would urge the medical profession and hospital  administrators to stop trying to be “balanced” on this issue. Sure it’s an inconvenience for all concerned. No doubt this can wreak havoc in terms of a hospital’s operating room scheduling. Too bad! Figure out ways to deal with “call schedules” then. Don’t place the onus on the patient. The health industry claims it is constantly in search of ways to improve safety. Well isn’t this a pretty simple issue to tackle if that’s the case?

What are your thoughts on this issue? Would you be concerned if the person holding the surgical instrument for your procedure has sleep deprivation? Would you ask the questions about their sleep patterns or how much sleep they got the night before? Should this be a patient’s burden? What policies make sense? Share your thoughts with our readers. Maybe – just maybe – the right people might read your comments and come up with some solid policies to protect all of us in such circumstances.

Image: peoplespharmacy.com

Failing Report Card for US Trauma Care: “fragmented, overwhelmed and under-funded”

Thursday, November 4th, 2010

From one of the country’s power trauma centers in San Diego California, Dr. Brent Eastman, Chief Medical Officer, Senior Vice President and Chair of Trauma at Scripps Memorial Hospital, as well as, Chairman of the Board of Regents for the American College of Surgeons (ACS) has sounded the warning alarms loud and clear.

Trauma Care in the US is fragmented, overwhelmed, and under-funded. High death rates in rural areas and a disconnect between existing trauma systems and regional preparedness adds to a bleak picture of the state of trauma care in the US.

Coordinated, regionalized, and accountable trauma systems are proven to get the right patients to the right hospitals at the right time. For victims of major trauma, access to timely,optimal care during the first golden hour has been proven to saves lives, restore function, and prevent disability.

Dr. Eastman is a national and international leader in the development of trauma centers in the US, England, Australia, Brazil, Argentina, Canada, Mexico, South Africa, India, and Pakistan. He has served as chairman on the CDC research steering committee, and the ACS Committee on Trauma Systems. He was a distinguished visiting surgeon in 2007 to the Combat Casualty Program at Landstuhl Medical Center in Germany. In 2009, he delivered the signature speech on trauma care the the annual ACS Clinical Congress. Dr. Eastman is a powerhouse with a powerful message.

  • US TRAUMA IS  FAILING.
  • THERE IS A SHORTAGE OF TRAUMA SURGEONS.
  • NEARLY 40% OF THE US POPULATION IS NOT COVERED BY STATE TRAUMA SYSTEMS. RURAL AND POOR AREAS ARE IN THE GREATEST NEED.
  • 38% OF STATES HAVE NO TRAUMA SYSTEM.
  • 62% OF STATES REPORT STATE FUNDING IS IN JEAPARDY; PROGRAMS ARE UNSUSTAINABLE.

The ACS has made 2 important databases available to the public. Their Committee on Trauma has published the listing of verified US trauma centers, and the National Trauma Databank Annual Report for 2010. Everyone should be familiar with their state’s data. If your state does not have a functional trauma care system during the best of times, then it surely will not function during more difficult times as in the event of a terrorist attack, earthquake, tornado, hurricane, serious fire with casualties, major multi-vehicle traffic accident, or other widespread disaster.

The ACS Committee on Trauma specifically verifies the presence of resources that are defined in Resources for Optimal Care of the Injured Patient. Trauma centers across the country voluntarily participate in the verification process. States where no trauma centers participated or where the resources were not sufficient to sustain even one verified center were Georgia, Florida, Maryland, Arkansas,  Hawaii, New York, Mississippi, Pennsylvania, South Carolina, Tennessee, and Washington.

If trauma centers in these states refused to participate, one must wonder why? Were they afraid of public disclosure of their shortfalls and/or financial troubles? Were they competitively afraid of not measuring up to other states? Perhaps it is poor coordination and communication within the state trauma systems as reported by Dr. Eastman? Or were they simply woefully underfunded and embarrassed?

In the NTDB Annual Report you will find 6 states had only 34% to 66% of the trauma centers submit outcome data. And 8 States had only 0% to 33% of the trauma centers submit outcome data. I have to wonder why there was not 100% participation. New York, Florida, Illinois, and Texas were among the under submitters. Other states included New Hampshire, West Virginia, Iowa, Oklahoma, Colorado, Washington, and Oregon.

It is surprising to me that New York, Florida, and Mississippi, where serious disasters have taken place and are at high risk for recurrence, have the least participation? I would think national trend data on trauma performance and needs would be critical to state and federal funding analysis and support?

As you scan the listing, you will see each state verified resources for Level I, II, and III trauma centers. The levels are determined by the ACS and defined as:

  • Level I – Treats a minimally required number of trauma patients each year. Offers 24 hour emergency treatment 7 days a week by a complete set of specialists including anesthesiologists, emergency and critical care, neurosurgeons, orthopedic surgeons, plastic surgeons, and other specialists. Offers full critical care services in addition to research, preventative, and outreach programs. Must be superior in injury prevention solutions, trauma education, and trauma recovery. Must be a major referral center for the neighboring regions.
  • Level II – Works in collaboration with the Level I center. May not have 24 hour availability of all needed specialists and professionals, but can provide the same trauma care and management as a Level I center. Does not have research or surgical residency programs.
  • Level III – Does not have 24 hour availability of specialists but can provide a comprehensive trauma care with emergency resuscitation, surgery, critical care required by most trauma patients.  Has transfer agreements with Level I and II centers for back-up of severely injured patients.

As you will see, Illinois has only 1 verified Level I trauma center. Alaska, Idaho, North and South Dakota, and Wyoming have no verified Level I trauma centers.

There was a Boston TV news expose in 2008 that revealed a state with some of the country’s finest medical facilities but who could not deliver the proper level of care.  There was a 2007 statewide survey where 62% of the state’s trauma patients didn’t get transported to a trauma center.  83% of patients who needed a helicopter transport didn’t have one called. In 1992 the National highway Traffic Safety Administration recommended Massachusetts set-up a state trauma registry. Data collection began in 2008, 16 years later and one month before the Boston news story broke.

Just do a search in your favorite search engine for trauma center in jeopardy and see all the articles that come up! Astounding.

Kudos to Georgia. I commend to you an article entitled, “The Quest for Sustainable Trauma Funding: The Georgia Story”, by Dennis W. Ashley, MD, FACS, FCCM in the October 2010 Bulletin of the American College of Surgeons. A fascinating read on how the state’s Trauma Services Study Committee responded to dismal 2006 performance and financial data. The Georgia trauma death rate was 20% below the national average; rural area death rates were much higher than the metropolitan rates; only 305 of trauma victims were treated in designated trauma centers; and the state was delivering $250 million in uncompensated trauma care annually. The death rate translated to 700 lives lost that could and should have been saved.

Dr. Ashley concluded, “It is imperative trauma surgeons do not try to develop a system or obtain funding on their own.” In Georgia the surgeons joined forces with the EMS, the Georgia Hospital Association, the Medical Association of Georgia, nursing associations, the Georgia Chamber of Commerce, state and local governments. With a unified directive, a statewide media campaign was begun to first educate the public on the issues, problems, and needs. Next,  the media and surveys were used to determine what Georgians were willing to pay for improved regional and statewide trauma care. These initiatives led to support for 2009 and 2010 legislative bills to fund improved trauma care.  Despite a terrible economy, adequate and sustainable trauma care in Georgia is finally becoming a reality.

It is a call to action in every community to be aware of your local community and region’s healthcare trauma needs and problems. Get involved, get the data!  It’s out there.