Written by: Medical Device Accident Expert Witness No. 3571
A patient underwent a trans-urethral resection of the prostate. The bladder was distended with sterile water hung about 1 meter above the patient and run through a fluid warming device. The surgery went as planned, but the patient later presented with pain and trouble urinating. Cystoscopy revealed what appeared to the surgeon to be a thermally burned lining of the bladder that was sloughing off. The bladder later necrosed and was surgically removed.
Pathology of the bladder found the bladder lining to have necrosed and sloughed, but the prostate, which was also removed, was pink and healing. No mention of any burn to the urethra was made.
If the bladder had been thermally burned during the surgery, the distending water would have to have been above 60°C, the temperature at which tissue proteins denature. If this was the case, then the prostate would also have been burned because it was opened to the water in the bladder. As this water flowed out through the metal resectoscope, the urethra would likely to have been burned as well. However, the surgeon and surgical technician had noted that the effluent water was warm but not hot. Additionally, the fluid warmer could not warm the water above 43°C. So something other than heat caused the bladder to necrose.
The 1950’s and 1960’s cystitis was sometimes treated by distending the bladder for up to 30 minutes. There are reports of bladder necrosis due to this treatment. Cystoscope and resectoscope instruction manuals warn against leaving the outflow stopped for long periods as this could cause necrosis of the bladder.
The bladder has a blood supply separate from the prostate, and is a thin walled structure like a balloon. When the bladder is distended, the blood vessels are forced shut by the tension in the bladder wall. If the blood flow is stopped for sufficient time, the tissue begins to die. Because the prostate has a separate blood supply, a more massive shape, and was being removed, it was not necrosed by the pressure.
We concluded that the bladder pressure had to have been maintained for sufficient time to cause bladder necrosis and that the fluid warmer did not overheat.
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Wednesday, October 26, 2011
Friday, October 14, 2011
Propofol to induce sleep?
Written by: Neurology and Neurophysiology Expert Witness No. 3614
One day a fellow physician came to my practice to be evaluated for a neurological condition. The staff wanted to know what "special measures" we should take for a VIP. Of course the answer to that is simple. If one is already providing the best care possible, the answer is "the same measures we take for everyone". If the answer were anything else, it would imply that every other patient received something less than optimal care.
It seems that at times certain patients receive care that is outside the established standards based on the patient's position, wealth, or notoriety. If excellent medical care is the standard, this deviation from standard practices will by definition provide something other than optimal care.
One of the most recent examples of practicing outside the standard of care is the case involving Michael Jackson and Dr. Conrad Murray. While the details of the case are still being discussed in court, it is clear that Michael Jackson was given the powerful anesthetic Propofol to induce "sleep".
Propofol (Diprivan) is a short-acting, intravenously administered hypnotic agent. Its uses include the induction and maintenance of general anesthesia, sedation for mechanically ventilated adults, and sedation for procedures typically performed in an operative setting with constant monitoring. Propofol acts on the GABAA receptor to slow the closing time of the channel. Activation of this receptor in the brain produces sedating effects. While there is some variability in how patients respond to Propofol, it is always highly sedating and commonly associated with decreased respirations.
The American Academy of Sleep Medicine has a number of suggestions for managing various forms of insomnia. While the use of some sedatives is considered useful, there has never been a recommendation for the use of general anesthetics. Such an idea is so far outside the standard of care that most physicians consider it comical at best.
For any physician dealing with a patient the most important aspect of the interaction is to practice within the standard of care. There is no level of notoriety or financial incentive on behalf of the patient that should warrant clear violations of that standard. Incidents of this nature are shameful and an embarrassment to the profession.
However, we can only speculate as to how many other physicians refused Michael Jackson's request for such medications and instead provided sound advice such as entering a coordinated drug rehabilitation program. Of course, any such physicians are not sitting in the courtroom today.
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Consolidated Consultants'
Your Source for FREE Nationwide Expert Witness Referrals
www.freereferral.com
One day a fellow physician came to my practice to be evaluated for a neurological condition. The staff wanted to know what "special measures" we should take for a VIP. Of course the answer to that is simple. If one is already providing the best care possible, the answer is "the same measures we take for everyone". If the answer were anything else, it would imply that every other patient received something less than optimal care.
It seems that at times certain patients receive care that is outside the established standards based on the patient's position, wealth, or notoriety. If excellent medical care is the standard, this deviation from standard practices will by definition provide something other than optimal care.
One of the most recent examples of practicing outside the standard of care is the case involving Michael Jackson and Dr. Conrad Murray. While the details of the case are still being discussed in court, it is clear that Michael Jackson was given the powerful anesthetic Propofol to induce "sleep".
Propofol (Diprivan) is a short-acting, intravenously administered hypnotic agent. Its uses include the induction and maintenance of general anesthesia, sedation for mechanically ventilated adults, and sedation for procedures typically performed in an operative setting with constant monitoring. Propofol acts on the GABAA receptor to slow the closing time of the channel. Activation of this receptor in the brain produces sedating effects. While there is some variability in how patients respond to Propofol, it is always highly sedating and commonly associated with decreased respirations.
The American Academy of Sleep Medicine has a number of suggestions for managing various forms of insomnia. While the use of some sedatives is considered useful, there has never been a recommendation for the use of general anesthetics. Such an idea is so far outside the standard of care that most physicians consider it comical at best.
For any physician dealing with a patient the most important aspect of the interaction is to practice within the standard of care. There is no level of notoriety or financial incentive on behalf of the patient that should warrant clear violations of that standard. Incidents of this nature are shameful and an embarrassment to the profession.
However, we can only speculate as to how many other physicians refused Michael Jackson's request for such medications and instead provided sound advice such as entering a coordinated drug rehabilitation program. Of course, any such physicians are not sitting in the courtroom today.
Click here to View Expert's Full CV
Consolidated Consultants'
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Tuesday, October 11, 2011
Is Justice Being Served?
"Hot Coffee" : Cup of Cheer for Plaintiffs
"Hot Coffee" is named for the high-profile 1994 case of an elderly New Mexico woman, Stella Liebeck, who spilled McDonald's coffee on herself and sued. Comedians, journalists and politicians mocked her case, adding momentum to the effort to cap damage awards.
The film is an aggressive attempt to channel the public's sympathy back to plaintiffs — using Liebeck's case and others. In graphic detail, it shows Liebeck's third-degree burns that required hospitalization and skin grafts, and it notes Liebeck settled out of court for an undisclosed amount likely far less than her initial $2.9 million jury award.
Business groups are beginning to denounce the film. A spokesman for the U.S. Chamber Institute for Legal Reform said it's as fanciful as the Flat Earth Society, while Victor Schwartz, who appears in the film as general counsel of the American Tort Reform Association, said he regrets participating in what he calls "the most effective piece of propaganda" that trial lawyers have ever put out. Read the whole story here...
The film is an aggressive attempt to channel the public's sympathy back to plaintiffs — using Liebeck's case and others. In graphic detail, it shows Liebeck's third-degree burns that required hospitalization and skin grafts, and it notes Liebeck settled out of court for an undisclosed amount likely far less than her initial $2.9 million jury award.
Business groups are beginning to denounce the film. A spokesman for the U.S. Chamber Institute for Legal Reform said it's as fanciful as the Flat Earth Society, while Victor Schwartz, who appears in the film as general counsel of the American Tort Reform Association, said he regrets participating in what he calls "the most effective piece of propaganda" that trial lawyers have ever put out. Read the whole story here...
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