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
Hysterectomy Leading to
Vesicovaginal Fistula

http://www.illustratedverdict.com/projectreview/IV/IV_1109web/2577m1_small.jpg

PLAINTIFF'S CLAIM:
The Plaintiff claimed that the Defendant was negligent in two respects: First, by bluntly dissecting during a total hysterectomy, thereby creating a vesicovaginal fistula through which urine leaked from the bladder into the vagina, and second, by failing to diagnose the existence of the fistula in a timely manner.

DEFENSE'S ARGUMENT:
This 36 year-old plaintiff underwent a hysterectomy because of abnormal vaginal bleeding and abdominal discomfort from a large, symptomatic 8–10 cm uterine fibroid. The patient’s anatomy was distorted by the mass, resulting in the cervix being pushed anteriorly into the base of the bladder.  This prevented normal visualization of the cervix on a speculum examination.

The manner in which the defendant performed the plaintiff’s hysterectomy—sharp dissection using scissors, as well as blunt dissection with her finger—was not only consistent with the standard of care but was (and still is) the method employed by many if not most gynecologists. 

During the patient’s post-op hospitalization, there were no signs or symptoms that a vesicovaginal fistula had formed. The fistula presumably developed slowly, as evidenced by her symptoms only becoming apparent weeks after surgery. The physician theorized that the slow development stemmed from devascularization of the bladder wall, most likely resulting from a pelvic infection.

VISUAL STRATEGY:
IV worked with the attorneys and experts to develop a visual strategy that would help explain to the jury in detail that the procedures were performed appropriately:

We began by showing normal anatomy to orient the jury to the anatomical landmarks and surrounding structures.

We also illustrated the preoperative condition and how the fibroid mass in the uterus distorted the patient’s pelvic anatomy.

We created illustrations of the hysterectomy directly from the operative reports with the cooperation of the experts and defendants.

We created illustrations of the postoperative anatomy.

With illustrations we were able to explain that the vesicovaginal fistula was not diagnosed immediately after surgery because it formed over an extended period of time.

  1. We illustrated the pelvic infection, showing adhesions between the small bowel and the adnexa, along with the resultant thinning of the bladder wall.
  2. We created a board to show how necrosis weakened the bladder wall and progressed into a vesicovaginal fistula.
  3. We illustrated the vesicovaginal fistula based specifically on case documentation and expert review.

We concluded with a timeline that helped the jury visualize that the care given and the follow-up recommendations and treatments were all appropriate.

This combination of illustrations helped the defense successfully explain that:

  • The manner in which the defendant performed the plaintiff’s hysterectomy—sharp dissection using scissors, as well as blunt dissection with her finger—was not only consistent with the standard of care but was (and still is) the method employed by many if not most gynecologists. 
  • The plaintiff did not have a vesicovaginal fistula during her postoperative hospitalization. The fistula developed slowly, becoming evident weeks later, presumably from devascularization of the bladder wall resulting from a pelvic infection. 

RESULT:
Arbitrator found in favor of the Defendant

In Arbitration: "He found for the defense.  I would like to thank all of you for your invaluable work in making this a successful outcome for our client. "
-- Attorney Dennis R. Anti, Partner, Morrison Mahoney LLP., Springfield MA