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
Alleged Airway Perforation vs.
Macklin Effect


A 66-year-old woman underwent an uneventful elective surgical hernia repair. The following day, she complained of increasing neck pain associated with progressive dysphagia (difficulty swallowing), odynophagia (painful swallowing) and mild dyspnea (shortness of breath). The clinical team performed a CAT scan of her neck and chest and it was significant for air in the parapharyngeal space of the neck with some extension into the mediastinum (middle section of chest cavity). A fiber optic laryngoscopy was performed at bedside and was notable for marked inflammation of the laryngeal mucosa with obliteration of pyriform sinus secondary to edema (swelling). The larynx (airway) was not acutely involved but it was decided to intubate to prevent risk of airway compromise in the event that the air mass within her neck expanded. She was taken to the operating room and a diagnostic direct laryngoscopy was performed where no obvious bleeding or lacerations were identified in her throat that could cause the air in her neck and chest.


The defendant allegedly caused an airway perforation during an endotracheal intubation and/or oral gastric (OG) tube suctioning. Plaintiff contends that the perforation caused air to infiltrate her airway tissues, resulting in airway edema.


The defense theory was that there was no perforation, and that the patient suffered the Macklin effect (burst alveolus in the lung) postoperatively, resulting in air entering the mediastinum and traveling up to the area of the airway tissues.



Collaborating with the defense attorney, IV's Demonstrative Evidence Group created a visual strategy that helped experts explain that the defendant's actions were not the cause of the free air mass in the plaintiff's neck and chest.

The first diagram was of the normal anatomy of the head, neck and thorax, presented as an overall view of the anatomy that would be discussed in the case.

The next diagram was used to demonstrate the positioning, instruments and technique of intubation.

Another diagram was created to illustrate the tubes in place during the intubation and OG suctioning.

The fourth diagram was an overview of the normal respiratory system.

The fifth diagram was of the defense theory; the Macklin Effect (burst alveolus in lung). The defense argued that the air originated from the lung and moved up the mediastinum into the neck.

The final diagram illustrated the subcutaneous air in her neck as well as how the mediastinum communicates with the fascial layers of the neck. It demonstrates a clear path for air to travel from the lungs up the neck.

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

  • The nature of the communication between the mediastinum and neck tissues.
  • Intubation is a precise procedure that was performed by the defendant within the standard of care.
  • The Macklin Effect theory is plausible as it fit the facts of the case.

The jury found in favor of the defense. 

"Defense verdict! We used all of the exhibits and they were excellent. Thanks again for all of your help.”

- Attorney Craig B. Merkle, Esq., Goodell, DeVries, Leech & Dann, LLP,
Baltimore, MD