In addition to my consulting work and writing the Health Business Blog, I’m chairman of the board of Advanced Practice Strategies, a medical risk management firm that provides litigation support for malpractice defense and an eLearning curriculum focused on enhancing patient safety. Here’s the Advanced Practice Strategies case of the month.
For previous examples see Fetal assessment and response, Stroke after lung surgery and Coronary artery disease vs. medication administration.
Illustrated Verdict by APS
|Judgment for the Defense
tPA Administration Leads to Brain Hemorrhage
The patient, an 80-year-old woman with severe peripheral vascular disease and impending gangrene in her right leg, was seen by the defendant, a vascular surgeon. She had previously undergone a femoral-tibial bypass in her right leg and had no pulse in her right foot. Her left leg had already been amputated above the knee after a failed bypass and she was now facing the possibility of losing her right leg. As a result, she wanted aggressive therapy to save her right leg and was admitted to the hospital for thrombolytic therapy and surgery to revise the graft.
Two days later, an angiogram of the patient’s right leg showed blood clots blocking the distal vessels as well as the bypass graft. She received intra-arterial thrombolysis to break down the blood clots, after which she suffered a stroke and became nonresponsive. The patient was given a brain CT scan, which showed a large intracerebral hemorrhage and she died within a few days.
The defendant testified that he discussed the potential, inherent complications of tPA therapy with the patient, including the possibility of a fatal hemorrhage. The patient, informed of these risks, opted for this aggressive treatment in an effort to save her right leg, rather than undergo an amputation because it would have led to a significant decrease in her functionality and independence.
We began by demonstrating the normal anatomy of the leg and foot.
We also used a posterior view of the normal vasculature to provide a greater understanding of the circulatory anatomy of the arteries and the branches that supply the foot.
We then created illustrations to show, comparatively, the effects of peripheral artery disease in the leg, with cross sections of the vessels and the occlusions that can cut off blood flow.
Next, we showed the patient’s anatomy with a functional femoral-tibial bypass and compared it to a blocked bypass. This helped demonstrate the severity of blockage in her leg and the lack of blood flow to her foot that resulted.
A visual was also created to show how a clot within a severely diseased leg can lead to gangrene, posing a fatal threat to the patient. This demonstrated that immediate action was warranted to clear the vessels of the clot.
To help the jury visualize what the defendant was trying to achieve by opening up the blood flow through the graft, we illustrated the tPA infusion (thrombolysis). The pre- and post-treatment films showed the tPA infusion was successful in this regard.
This combination of illustrations helped the defense successfully explain that:
“APS was very helpful in taking the complex medical issues in the case and simplifying them with the medical visuals. The timelines that were created were used in the opening and closing statements and I believe they helped solidify the jury’s understanding of the case as a whole.”