IV Case in Point
Illustrated Verdict shares case examples from our archives to show how a visual strategy can support the defense effort. We hope that it is of value in your practice as you develop your defense strategies on behalf of health care providers. Please feel free to forward it to colleagues or clients.

About Us
IV is a leading provider of demonstrative evidence for the defense of medical malpractice claims. Our team of medical illustrators consults with defense teams to educate the lay jury audience about the complexities of medical care. We do this by developing a visual strategy with expert witnesses including high-quality case-specific medical illustrations, x-ray enhancements, and multimedia presentations. IV receives judgment for the defense in over 94% of the cases we participate in, as compared to the national average of 73%. Additionally, insurers who supply us with their trial list enjoy a win rate of up to 97%.
To learn more, e-mail us or call 617-530-1001.
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Case In Point Library
Click to view other editions:

Case In Point Library Page

Pregnancy and Delivery:
Fetal Assessment 2009v1
Shoulder Dystocia 2009v3
MVA Leads to Fetal Demise 2010v4
Fetal Descent Stalled 2010v5
Shoulder Dystocia / Erb's 2011v4
Fetal Tracings / Hypoxic Injury? 2013v1

Heart:
Coronary Artery Disease 2009v5
CAD / Recurrent MI 2010v1
Aortic Valve Replacement 2011v1

Lungs:
Stroke After Lung Surgery 2009v2
PE / Infection 2010v3
PE Following Roux En Y 2012v1
Intubation / Macklin Effect 2012v4
Lung Cancer vs. Infection 2015v3

Female Pelvis:
Hysterectomy / Fistula 2011v9
Hysterectomy / Ureter Injury 2010v2
Hysterectomy / Kinked Ureter 2010v8
Diag Lap / Bowel Injury 2012v3
Cervical Cancer 2013v3
Endometrial Cancer 2014v1

Male Pelvis:
Bladder Cancer 2013v2

Digestive System:
Gastric Bypass 2009v6
Recurrent Hiatal Hernia 2009v8
Right Colectomy / Leak 2010v7
Gastric Bypass / Volvulus 2011v2
Nissen Fundoplication 2011v3
Large Hiatal Hernia 2013v5
Necrotizing Enterocolitis 2013v7
Arrest during ERCP 2015v4
Diverticulitis Complications 2015v5

Abdomen:
Spleen Injury and Bleed 2009v4
Bleed Following Lithotripsy 2012v2
Lap Cholecystectomy 2012v5
Bowel Injury Lap Ovarian Cyst Removal 2013v6
LapChole - Hepatic Duct Injury2015v1

Orthopedic:
Partial Hip Replacement 2010v6

Vasculature:
tPA Infusion 2009v7
Vertebral A. Coil Embolization 2015v7

Head and Neck:
Bell's Palsy 2013v4
Tongue Cancer 2014v2
Chiari I - Vision Loss 2015v2

Judgment for the Defense
tPA Administration Leads to
Brain Hemorrhage

http://www.illustratedverdict.com/projectreview/IV/IV_0809web/1940m4.jpg

PLAINTIFF'S CLAIM:
Wrongful death from the administration of tPA (Tissue Plasminogen Activator) which led to a fatal 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.

DEFENSE'S ARGUMENT:
Thrombolysis is a common treatment of peripheral vascular disease, either on its own or as a precursor to surgery. The most serious potential side effect is bleeding in various body parts, including the arterial puncture site or in the brain. To minimize this risk, the treatment is not generally administered to patients with a history of intracranial hemorrhage, uncontrolled hypertension, recent stroke, or a bleeding disorder.  However, the patient presented with none of these risk factors.

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.

VISUAL STRATEGY:
IV worked with the attorneys and experts to develop a visual strategy that would help explain to the jury in detail how peripheral artery disease presents itself and the issues of treatment:

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.

Lastly, we created timelines to help give the jury a better understanding of the patient's history and the treatment she received while in the hospital.

This combination of illustrations helped the defense successfully explain that:

  • The patient had a very serious condition and needed immediate action to save her limb and her life;
  • The tPA infusion is a commonly accepted therapy to clear clots in vessels; and
  • While the clotting abnormalities induced by the treatment resulted in an unusually large and ultimately fatal hemorrhage, this is an inherent complication. The risk was fully explained to the patient prior to the treatment and she had given her informed consent.

RESULT:
The jury found in favor of the defense. 

“IV 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.”
-- Attorney Dennis R. Anti, Partner, Morrison Mahoney LLP., Springfield MA