Vascular Surgery Expert Witness

Vascular Complications Associated with Diabetes

A number of vascular surgery complications occur as a result of diabetes. In fact diabetes can accelerate the progression of vascular diseae and may limit the ability to manage vascular occlusive disease. In one particular pattern of occlusive disease, the small microvasculature is impaired and the gross blood vessels ae intact. This may make bypass ineffective in the treatment of a nonhealing wound or limb gangrene. A patient suffering from this pattern may lose their limb despite successful bypass.

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	Blindness - Blindness caused by Diabetes is a serious complication of poorly controlled diabetes.
	Foot amputation - Poorly controlled Diabetes is the leading cause of nontraumatic foot and leg amputation in the United States.
	Kidney Disease - Poorly treated Diabetes is the leading cause of severe Kidney Disease, accounting for 44% of new cases each year.
	Neuropathy and Nerve Damage - One of the most common complications of diabetes is diabetic neuropathy, or severe nerve damage.
	Heart Disease and Stroke - Most people with diabetes also have high blood pressure and cholesterol that increase their risk for heart disease and stroke. Learn more...

Medical Malpractice Statistics for Surgery

 Startling information that medical malpractice lawsuits are more frequently directed at physician extenders.

A sign of the changing face of healthcare.

General medical malpractice statistics related to surgery malpractice in the USA:

• Nearly 50% of malpractice trials were against surgeons in 75 of the largest counties in the US 2001 (Bureau of Justice Statistics)
• Nearly 33% of malpractice trials were against nonsurgeons in 75 of the largest counties in the US 2001 (Bureau of Justice Statistics)
• Roughly 50% of medical malpractice trials related to surgeons in the 75 largest counties in the US 2001 (Bureau of Justice Statistics, US Department of Justice)
• Roughly 33% of medical malpractice trials related to nonsurgeons in the 75 largest counties in the US 2001 (Bureau of Justice Statistics, US Department of Justice)
• Roughly 23% of medical malpractice trials against nonsurgeon doctors were won by the plaintiff in the 75 largest counties in the US 2001 (Bureau of Justice Statistics, US Department of Justice)
• Roughly 26.5% of medical malpractice trials against surgeons were won by the plaintiff in the 75 largest counties in the US 2001 (Bureau of Justice Statistics, US Department of Justice)

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Medical malpractice lawsuit payment statistics for surgery malpractice in the USA:

• 4,132 medical malpractice payments were made due to surgery related malpractice in the US 2002 (2002 Annual Report, National Practitioner Data Bank, US DHHS)
• $222,285 was the mean medical malpractice payments made due to surgery related malpractice in the US 2002 (2002 Annual Report, National Practitioner Data Bank, US DHHS)
• $115,000 was the median medical malpractice payments made due to surgery related malpractice in the US 2002 (2002 Annual Report, National Practitioner Data Bank, US DHHS)
• 49,429 medical malpractice payments were made due to surgery related malpractice in the US 1990-2002 (2002 Annual Report, National Practitioner Data Bank, US DHHS)
• $172,172 was the mean medical malpractice payments made due to surgery related malpractice in the US 1990-2002 (2002 Annual Report, National Practitioner Data Bank, US DHHS)
• $82,500 was the median medical malpractice payments made due to surgery related malpractice in the US 1990-2002 (2002 Annual Report, National Practitioner Data Bank, US DHHS)

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Medical malpractice lawsuit payment report statistics for surgery-related malpractice in the USA:

• There were 28,102 surgery related primary malpractice acts or omissions in the US 1990-96 (The National Practitioner Data Bank Public Use File)
• 24% of primary malpractice acts or omissions were surgery related in the US 1990-96 (The National Practitioner Data Bank Public Use File)
• $3,851,200,397 in payments were made for surgery related primary malpractice acts or omissions in the US 1990-96 (The National Practitioner Data Bank Public Use File)

 

Medical malpractice lawsuit payment statistics for surgery malpractice in the USA:

• There was a 5.56 year mean time delay between surgery related malpractice incident and payment in the US 2002 (2002 Annual Report, National Practitioner Data Bank, US DHHS)
• There was a 4.63 year median time delay between surgery related malpractice incident and payment in the US 2002 (2002 Annual Report, National Practitioner Data Bank, US DHHS)

Medical malpractice lawsuit payment statistics for surgery malpractice and nurses in the USA:

• 274 surgery related malpractice payment reports were made against registered nurses in the US 1990-2002 (2002 Annual Report, National Practitioner Data Bank, US DHHS)
• 46 surgery related malpractice payment reports were made against nurse anaesthetists in the US 1990-2002 (2002 Annual Report, National Practitioner Data Bank, US DHHS)
• 7 surgery related malpractice payment reports were made against nurse midwives in the US 1990-2002 (2002 Annual Report, National Practitioner Data Bank, US DHHS)
• 5 surgery related malpractice payment reports were made against nurse practitioners in the US 1990-2002 (2002 Annual Report, National Practitioner Data Bank, US DHHS)
• 1 surgery related malpractice payment reports were made against advanced nurse practitioners in the US 1990-2002 (2002 Annual Report, National Practitioner Data Bank, US DHHS)

Timely limb amputation can be life saving

Limb amputation is frequently characterized as a failure in the system however there are some instances when limb amputation in patients with chronic arterial disease or nonhealing wounds can be the most direct route to obtaining better function with improved quality of life.

Learn about foot disorders/find an attorney

Various modalities exist for limb salvage including angioplasty, stenting and atherectomy. Atherectomy in particular has gathered a great deal of steam over the past 5 years.

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All of these modalities have a select group of patients who they are most appropriate for and they all have limitations. For the patient who presents with severe infection with gas gangrene, prompt amputation with staged revision can be life saving. Conversely, I have seen some patients with chronic ulcers of the heel who undergo multiple procedures in an attempt to reconstruct a foot which may never be weight bearing.

The take home message is to consult a practioner who specializes in limb salvage using the state of the art technology and experience to know what treatment is appropriate for each individual patient. 

 

 

Will further reducing work hours enhance patient safety

This is an interesting revision to patient work hours. In an effort to reduce medical errors.

Inexperienced Resident Doctors to Receive More Supervision in Malpractice Prevention Effort

A newly minted M.D. doctor wandering the halls of a hospital, working long hours with little sleep as he or she begins years of residency training, can be a potential disaster waiting to happen. That's the source of the old bromide about July being the most dangerous month to get sick, since that's when residency programs start their new year.

In theory, all junior doctors receive careful supervision from senior doctors in training and from full-fledged "attending" physicians. But in practice, in busy institutions junior doctors can work long hours with little supervision, and mistakes that cause injuries to patients can result.

In 2003, residency programs accredited by the official supervisory body, the ACGME, were required to cut resident work weeks from 120 to 80 hours. But in December 2008, the Institute of Medicine, part of the National Academies of Sciences, recommended more changes to improve patient safety in residency programs.

One of them was to end the practice of 24-hour shifts.

The ACGME is now following that advice, but only in part. As of July 2011, first-year residents will be limited to 16-hour shifts, but after the first year, residents will still be able to work a 24-hour shift. Many experts believe the longer shifts are dangerous for patient safety because of sleep deprivation.

The 16-hour limit for first-years is part of a series of recommendations being submitted to the ACGME board for final approval in a few months.

Sidney Wolfe, MD., head of Public Citizen Health Research Group, is critical of the failure of the ACGME to propose a 16-hour limit across the board. He says: "The improvements in the new ACGME guidelines are largely swamped by the failure to cover the majority of medical residents with the protection of not having to work more than 16 hours continuously."

In the new proposal, first-year residents would also be barred from moonlighting at other jobs and from being "on call" in hospitals.

Source

A newly minted M.D. doctor wandering the halls of a hospital, working long hours with little sleep as he or she begins years of residency training, can be a potential disaster waiting to happen. That's the source of the old bromide about July being the most dangerous month to get sick, since that's when residency programs start their new year.

In theory, all junior doctors receive careful supervision from senior doctors in training and from full-fledged "attending" physicians. But in practice, in busy institutions junior doctors can work long hours with little supervision, and mistakes that cause injuries to patients can result.

In 2003, residency programs accredited by the official supervisory body, the ACGME, were required to cut resident work weeks from 120 to 80 hours. But in December 2008, the Institute of Medicine, part of the National Academies of Sciences, recommended more changes to improve patient safety in residency programs.

One of them was to end the practice of 24-hour shifts.

The ACGME is now following that advice, but only in part. As of July 2011, first-year residents will be limited to 16-hour shifts, but after the first year, residents will still be able to work a 24-hour shift. Many experts believe the longer shifts are dangerous for patient safety because of sleep deprivation.

The 16-hour limit for first-years is part of a series of recommendations being submitted to the ACGME board for final approval in a few months.

Sidney Wolfe, MD., head of Public Citizen Health Research Group, is critical of the failure of the ACGME to propose a 16-hour limit across the board. He says: "The improvements in the new ACGME guidelines are largely swamped by the failure to cover the majority of medical residents with the protection of not having to work more than 16 hours continuously."

In the new proposal, first-year residents would also be barred from moonlighting at other jobs and from being "on call" in hospitals.

Source

Graft infection a complication of vascular surgeon

Arterial bypass graft infection is a recognized and accepted risk in all surgeries and may be catastrophic in vascular surgery intervention.  Vascular surgery patients frequently suffer from additional co morbid conditions that can make them more prone to local and systemic infections. Appropriate precautions including sterile operative technique can reduce but not eliminate the risk of peri-operative infection.

Prophylactic Antibiotics Prior to Bacteremia Decrease Endovascular Graft Infection in Dogs

Lee Kirksey, MD

Bruce J. Brener, MD

Steven Hertz, MD

Victor Parsonnet, MD

Department of Surgery, Newark Beth Israel Medical Center, Newark, NJ

Endovascular placement of vascular stent grafts in the aorta and peripheral vessels has become a prominent tool in the armamentaria of the vascular surgeon. Despite, several reports of stent graft infection, no current guidelines exist regarding the administration of antibiotics prior to episodes of potential bacterial seeding. We sought to clarify the role of prophylactic antibiotics in preventing stent graft infection after the parenteral administration of Staphylococcus aureus (S. aureus) at various intervals following device placement. A stent graft device was constructed from a 4 mm thin-walled polytetrafluoroethylene (PTFE) graft attached to the outside of a balloon expandable 394-Palmaz stent (Johnson and Johnson Interventional Systems, Warren, NJ). It was then inserted into the common iliac artery through an 1 IF peal-away sheath placed in the femoral artery. Sixty grafts were placed into 30 dogs. There were 5 groups of equal number (groups A-E). In group A, six dogs received intravenous injection of 3 cc X 104 CFU (colony forming units), biotype 31375 5. aureus, 1 day after stent graft implantation. An identically treated group B received antibiotic prophylaxis (1 gm cefazolin 30 minutes prior to bacterial challenge). Group C received bacterial injection 7 days after graft implantation with no antibiotic prophylaxis. Group D received bacterial injection 7 days after graft implantation with antibiotic prophylaxis. A control group E received no antibiotics and was not infected. All infected animals were sacrificed 7 days following bacterial challenge and the stent graft complex cultured. One half of the control group was sacrificed at 7 days and the other half at 14 days. The overall stent graft patency was 90%. Four of the six graft occlusions occurred in group A. Eleven of 12 (92%) dogs cultured S. aureus (biotype 31375) from the explanted stent graft complex. Two localized perforations occurred at the site of the infected complex. In group B, C, and D, no explanted graft complex cultured S. aureus. One graft occluded in group C and D. No stent graft in the control (group E) cultured S. aureus. A stent graft infection model can be consistently produced. In the canine model, the stent graft is more susceptible to infection in the early postoperative period and becomes less susceptible to bacterial seeding at one week after implantation. The authors recommend the use of prophylactic antibiotics in the prevention of endovascular graft infections in the early postoperative period during times when bacterial seeding may occur. They postulate that pseudointima formation during graft incorporation into the vessel wall may be responsible for the resistance to infection.

HemoDialysis Access innovation in 2010 from EVToday

Evolution in vascular access technology continues to evolve. These critical changes are essential in this challenging patient population

In the 1930s, Willem Kolff, MD, developed an apparatus for treating patients with acute renal failure by hemodialysis. However, the use of this life-saving technology was limited because it required repeated access to the vascular system. In many ways, advances in the care of patients with end-stage renal disease (ESRD) have mirrored the advances in vascular access technologies. Although external Teflon shunts (Figure 1) and native arteriovenous fistulae were the initial cannulation options for dialysis access, it was clear that not all patients requiring renal replacement therapy would have the anatomy suitable to create an autogenous artery-tovein fistula due to an array of hemodynamic or anatomic factors that would result in fistula failure.

In an attempt to solve this problem, the concept of a “bridge fistula” or dialysis graft was developed. Initially, the great saphenous vein was used as a conduit, but in the 1970s, the use of expanded polytetrafluoroethylene (ePTFE) was pioneered as a suitable vascular graft and was rapidly adopted as an alternative material for connecting arteries and veins in an array of locations in the body.¹ The conception of prosthetic grafts revolutionized vascular access and gave rise to a number of new access sites that were previously unavailable for creating an arteriovenous fistula. However, with the advance of this new vascular access technology came a new set of complications and costs for the health care system. Today, the health and social realities of ESRD are tremendous, with economic costs in the United States exceeding $33 billion in 2006.²

CURRENT CHALLENGES
Vascular access circuits in general and nonautogenous conduits in particular have historically been plagued by multiple difficulties. Although prosthetic conduits have been pivotal in providing vascular access for the ESRD population, patency and infection rates are inferior to those of autogenous fistulae.^3-5

Venous neointimal hyperplasia occurring at the graftvein anastomosis outflow tract is cited as the most common factor in access failure (Figure 2).⁶ Intimal hyperplasia is well described; however, in the case of vascular access, there are numerous potential causative factors that are not completely understood and are under active investigation.⁷ Anatomic and physiologic barriers also affect the success of hemodialysis grafts because no vascular access conduit will function properly without adequate arterial inflow or venous drainage. One of the most common pathologies that alters graft outflow and limits patency is central venous stenosis and/or occlusion, which typically results from prior insertion of multiple tunneled dialysis catheters (TDCs).

Thrombosis can occur as a result of numerous factors such as intimal hyperplasia, graft trauma, low flow states, and hypercoagulable disorders.⁸ Intimal hyperplasia causes hemodynamic conditions of low and turbulent flow states, which leads to platelet aggregation at focal points within the arteriovenous graft (AVG) and promotes thrombosis.⁷

^Source

 

The following tort reform may have significant impact on medical malpractice in Georgia. Both for emergency room doctors as well as those working with them inluding vascular surgeons.

Tort Reform Upheld by Georgia Supreme Court

By Tanya Roth on March 16, 2010 2:30 PM |

Yesterday, the Georgia Supreme Court handed down two cases that will have a strong impact on tort reform in the state. Whether or not the citizens of Georgia will like the result may depend on which side of the courtroom they are on now, or in the future. The first case the Court decided involves the increased burden of proof on plaintiffs in medical malpractice suits against ER doctors, the second, a penalty for plaintiffs in tort suits who refuse good faith settlement offers.

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The Atlanta Journal-Constitution reports the first case was originally brought by Carol Gliemmo who went to a Columbus, Ga. hospital in 2007 and was seen by an ER doctor for severe head pain. She was sent home with pain reliever and subsequently suffered a brain hemorrhage that left her paralyzed. In a 4-3 decision, the Court majority found the legislature had a legitimate interest in controlling medical malpractice costs. Further, the Court held that the circumstances of emergency treatment require quick life or death decisions sometimes made without knowing the medical history of the patient. The law approved by the Court now requires plaintiffs to establish by "clear and convincing evidence" that an ER physician committed "gross negligence," which has been defined under Georgia law as the failure to exercise even a slight degree of care.

Michael Terry, who argued the case on behalf of Gliemmo and her husband, said the decision will make emergency room practice less safe. "An ER doctor is now the one professional who is free to be negligent without legal repercussion," he told The Journal-Constitution.

The second case involved a defamation suit by a salon owner against former Atlanta Falcon Chuck Smith, who made disparaging comments during a radio interview about the treatment his daughter received at the salon. The salon owner, Cheryl Baptiste, sued but turned down the $5,000 Smith offered to settle. After Smith prevailed in court, Baptiste was then (under the tort reform law) responsible for $50,000 in attorney's fees. The court upheld the result in a 5-2 decision. Smith's attorney called the law an "effective tool for both plaintiffs and defendants."

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The Court will hear one more tort reform case regarding a $350,000 cap on jury awards in medical malpractice suits. That case will go before the court by the end of March.

Source

Interesting news from Georgia medical malpractice

State high court overturns state's tort reform 

By Bill Rankin

The Atlanta Journal-Constitution

A unanimous Georgia Supreme Court on Monday struck down limits on jury awards in medical malpractice cases, the cornerstone of the state's sweeping 2005 tort reform law.

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The state high court determined that a $350,000 cap on noneconomic damages, which includes compensation for a plaintiff's pain and suffering, violates the right to a jury trial as guaranteed under the Georgia Constitution.

The ruling upheld a $1.265 million jury award to Marietta real estate agent Betty Nestlehutt, now 75. After a face-lift operation in 2006, Nestlehutt's face was covered with gaping wounds that required prolonged, excruciating treatments to keep them from becoming infected. The wounds left her permanently disfigured.

In its decision, the state Supreme Court noted that the right to a jury trial for negligence claims against health care providers predates the adoption of Georgia's Constitution in 1798.

The 2005 law's cap on damage awards "clearly nullifies the jury's findings of fact regarding damages and thereby undermines the jury's basic function," Chief Justice Carol Hunstein wrote for the court. She added, "The very existence of the caps, in any amount, is violative of the right to trial by jury."

The decision puts the General Assembly on notice that any renewed effort to impose caps on jury awards will be futile, said Atlanta lawyer Michael Terry, who argued the case on Nestlehutt's behalf. "The court was very clear in saying, ‘You can't do this.' "

House Majority Leader Jerry Keen (R-St. Simons Island), a supporter of the limits, said he did not know what the Legislature could do in response. Up to now, he said, the law has served its purpose.

"As everyone knows it has created a greater degree of access to health care," Keen said. "We've had doctors moving into the state rather than leaving."

Senate Judiciary Committee chairman Preston Smith (R-Rome), a sponsor of the legislation, said, "We have taken a step back. Our rates will be more expensive and less accessible."

Georgia's 2005 tort reform law sparked intense legislative debate and pitted medical and hospital associations against trial lawyers and consumer groups. Last week, in a 4-3 decision, the state Supreme Court upheld another key provision of the law that makes it almost impossible for patients to recover damages in malpractice cases involving emergency room care.

MAG Mutual Insurance Co., which provides malpractice insurance to most Georgia doctors, said its insurance premiums have dropped since the tort reform law was enacted five years ago. "This is a setback for Georgia citizens seeking medical care and a defeat for Georgia's citizens," Roy Vandiver, MAG Mutual's chairman, said of Monday's decision.

Danny Orrock, deputy director of the consumer group Georgia Watch, applauded the ruling. "The decision favors the protection of patients and their constitutional rights," he said. "It restores the promise of justice for all and the rights of all Georgians -- young and old, rich and poor -- to access the courts."

About two dozen states have enacted caps on damage awards in medical malpractice cases. Last month, the Illinois Supreme Court declared unconstitutional a $500,000 cap against doctors and a $1 million cap against hospitals. Georgia's tort reform law limited awards to $350,000 against doctors and capped total awards at $1.05 million in cases involving multiple health-care providers and medical facilities.

After a trial, a Fulton County jury awarded Nestlehutt $115,000 for past and future medical expenses and awarded Nestlehutt and her husband, Bruce, $1.15 million in noneconomic damages, including $900,000 for her pain and suffering. Atlanta Oculoplastic Surgery and Dr. Harvey "Chip" Cole, who performed the operation, appealed the judgment, contending the Nestlehutts should receive no more than $465,000 -- including $115,000 for the medical expenses and the $350,000 cap.

Because the state Supreme Court found that caps on damage awards violate the Georgia Constitution, there will be no further appeal, Cole's lawyer, Jonathan Peters, said.

Atlanta attorney Adam Malone, who represented Nestlehutt at trial, said his client was the face of her real estate business and decided to have surgery when she found more and more clients seemed to prefer younger agents. But after the face-lift, Nestlehutt's face was so disfigured she no longer left home, he said.

Malone said the $900,000 jury award for the devastation of Nestlehutt's quality of life was justified and the Georgia Supreme Court did the right thing in upholding it. "The bedrock of our democracy depends upon our ability to self-govern at the ballot box and in the jury box," he said. "Any attempt by the government to invade either is an assault on what separates America from the rest of the world."

Staff writers Aaron Gould Sheinin and Ernie Suggs contributed to this article.

Source

Vacation Traveling is risk to dialysis patient

Travel May Be Hazardous To Dialysis Patients

Main Category: Urology / Nephrology
Also Included In: Conferences
Article Date: 31 Oct 2009 -

If you're sick, traveling to a foreign land may boost your spirits, but jeopardize your health, according to a paper being presented at the American Society of Nephrology's 42nd Annual Meeting and Scientific Exposition in San Diego, CA. The findings indicate that dialysis patients who travel on vacation risk infections, anemia, and other complications that can compromise their dialysis treatments.

In a study conceived and led by nurses, Claire Edwards, RGN; Kathleen Lynch, RGN; Neill Duncan, MRCP (West London Renal and Transplant Centre, Imperial College Kidney and Transplant Institute, United Kingdom); and their colleagues collected health information on patients who traveled on vacation at some point between April 2008 to March 2009. Their analysis included 69 patients of diverse ethnic background who traveled to Europe, the Middle East, India, the United States, Africa, the Pacific Rim, and South Asia.

One patient died during travel and two damaged or lost their fistulas or grafts (surgically created sites that provide dialysis tubes access to the blood). Seven patients required blood transfusions soon after their return, and several acquired blood stream infections.

The investigators concluded that travel among dialysis patients is associated with significantly increased infection rates, loss of vascular access, and anemia. "Many patients wish to travel freely around the world. This study empowers patients with information in order for them to make choices about their lifestyle," said Edwards.

The study is limited by the fact that the precise details of treatment received by patients, including treatment duration, blood loss, infection, antibiotic starts, etc while patients were on vacation was not always clear. There is no data for non-dialysis travelers, but the risks are expected to be significantly lower.

The authors report no financial disclosures. Study co-authors include Kathleen Lynch, RGN, Seema Singh, MSc, Damien Ashby, MRCP, David Taube, FRCP, Thomas Cairns, FRCP, Adam McLean, FRCP, DPhil, and Megan Griffith, FRCP, PhD (West London Renal and Transplant Centre, Imperial College Kidney and Transplant Institute, United Kingdom).

Source: American Society of Nephrology (ASN)

Medical Malpractice Defense Strategies

Defenses to Medical Malpractice: Patients' Negligence

The following lists some of the common medica malpractice defense strategies which can be extrapolated to various clinical specialties. ie the patient who suffers from severe vascular disease and has been counseled repeatedly about the detriment that continued smoking will have on his vascular system. Despite this he continues to smoke and ultimately develops a gangrenous ulcer on the foot. During his evaluation for leg bypass to improve circulation to the foot and heal the ulcer- he undergoes routing cardiac testing which reveals severe heart disease that must be fixed prior to the leg bypass. He undergoes the heart bypass with a somewhat bumpy post operative course that involves prolonged relatively lower blood pressures. His foot wound ultimately worsens before the leg bypass can be performed. He requires amputation because the leg is not salvageable any longer. He sues the vascular surgeon claiming that the delay in care resulted in his loss of limb.

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As malpractice is a form of negligence, defenses that are generally allowed against general claims of negligence are also viable against claims of malpractice. These might include the following defenses:

• The patient was also negligent and caused much of his or her own harm
• The patient failed to mitigate his or her own harm or damage, or made the harm or damage worse
• The patient gave an informed consent and therefore assumed the risk of any complication or untoward effect
• The alleged harm or damage was an unavoidable "known risk" that occurs without negligence
• The patient failed to disclose important information to the doctor
• The patient's prognosis or condition was not worsened by the alleged negligence
• The patient engaged in some intervening or superceding conduct following the alleged malpractice that broke the chain of events linking the malpractice to the patient's damages or harm

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