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%.
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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

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

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

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

Partial Hip Replacement 2010v6

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
Post Op Bleed Following Lithotripsy


Plaintiff was a woman with an extensive history of kidney and ureteral stones. The defendant recommended lithotripsy, a procedure which mitigates kidney stones by passing a targeted, machine-generated shock wave through the patient. The day following the procedure, the plaintiff was brought into the ER after a fainting spell and had a CT scan done. The radiologist read the CT scan and found blood around the spleen that he interpreted as indicative of a splenic rupture, a known, although rare, risk of lithotripsy. The plaintiff was then taken into the OR to have her spleen removed to stop the bleeding.


The plaintiff suffered a splenic rupture and bleed from negligence of the defendant during the lithotripsy. She had additional pain and suffering from the surgery to remove her spleen and a lengthened hospital stay.


The defense believed that the defendant followed the proper standard of care at all times during her care of the plaintiff. Ruptured spleens are a rare but known risk of lithotripsy. An important part of the defense was that the spleen is in the pathway of the shock wave. The shock wave starts out as a larger area and then cones down into a smaller, more concentrated area that targets the stones in the kidney.

When the plaintiff was admitted through the ER the day following the lithotripsy procedure she was not under the care of the defendant. During this admission she was given an additional drug, Toradol, which inhibits platelet aggregation. The defense believed that this added to the postoperative bleed that she presented with initially.

When the plaintiff’s spleen was removed, no true rupture to the splenic surface was found. It was never proven where the bleed actually came from, but it was believed to have come from the surface of the spleen.



Collaborating with the defense experts and attorney, IV created a visual strategy that helped the experts and defendant explain the defense’s position that the defendant properly followed the standard of care during and after the lithotripsy procedure.

The first diagram illustrated the normal anatomy of the kidney.

The following board was used to illustrate the normal anatomy of the upper abdomen. This helped show the relationship of the kidney to the spleen.

The next diagram demonstrated a before and after image of the kidney stones and post-lithotripsy procedure with the stones broken down.

The fourth diagram showed the machine that was used in the lithotripsy procedure and also a cross section at the level of the shock wave. This was important to illustrate how the shock wave cones down and to show that the lower portion of the spleen was in the pathway of the waves.

The fifth diagram showed the impact of the shock wave on the kidney and areas affected by direct and residual waves. The diagram also showed how the shock wave cones down and is concentrated on the stones in the kidneys.

The final diagrams demonstrate the preoperative films and postoperative films. The preoperative enhanced films were extremely important as they show the plaintiff’s specific anatomy and how the spleen was in the path of the shock waves. The postoperative films were used to show the bleed that occurred.

This series of illustrations helped the defense successfully convey to the jury the following key points:

  • The lithotripsy procedure was performed appropriately within the standard of care.
  • The risks of bleeds were an unfortunate known rare complication of the procedure.


The jury found in favor of the defense. 

"The jury came back our way 12-0. Thanks for all your help. The illustrations were absolutely key in achieving victory."

- Attorney, James P. Reinert, Esq., Gonnerman Reinert, LLC,
St. Louis, MO