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
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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
Complications of a Large Hiatal Hernia

In 1997, the plaintiff was diagnosed with a hiatal hernia. As she was asymptomatic, her physician treated her as a, “wait-and-see” and decided to not perform surgery right away because of the risks. In 2004, she became symptomatic and was diagnosed by the defendant with an incarcerated paraesophageal hernia. The defendant then recommended surgery, which the plaintiff declined at the time. In August 2009 she went to the ER with an abrupt onset of moderate abdominal pain and vomiting from the previous night. Her medical history of hiatal hernia was recorded in the ER documentation; her CT scan was notable for a, “very large hiatus hernia... marked distension of the stomach, which contains fluid and small amt. of gas.” She was seen by a GI and surgical consult and it was recommended she have surgery to repair. She had a total gastrectomy (removal of stomach) and thoracotomy and esophageal exclusion. She had a second surgery a few days later, involving a roux-y limb for esophagojejunostomy (connection between esophagus and jejunum), feeding jejunostomy, mobilization of her esophagus, esophageal spit fistula in the neck, and tracheostomy. The hospitalization in August 2009 was the basis for the lawsuit.

 

 

PLAINTIFF'S CLAIM:

Plaintiff claims that the patient would have been fine and avoided the complicated surgical procedures if the defendants had inserted a nasogastric tube when she was initially admitted in August 2009.

 

 

DEFENSE'S ARGUMENT:

Defense claimed that the twisting of the stomach that occurred with the incarcerated paraesophageal hernia would not have allowed for nasogastric tube placement as the risk of puncturing the esophagus was too great.

 




VISUAL STRATEGY:

Collaborating with the defense attorney and experts, IV created a visual strategy that helped explain that the defendant’s actions were within the standard of care.


The first diagram was of normal anatomy of the upper GI and a detail of the GE junction.


The second diagram demonstrated the location of a nasogastric tube in a normal stomach.


The next diagram was used to show the anatomy of a normal stomach and the surrounding anatomy under the diaphragm.


The fourth diagram illustrated a large hiatal hernia and how it twists on the mesentery causing an inversion of the stomach from right to left (becoming an incarcerated hernia).


We were then able to use the xray films to create an image of her large hiatal hernia with a color film enhancement. We compared her anatomy to an example of what a normal anatomy would look like.


The final diagram used was especially important in showing how a nasogastric tube could cause a perforation if it were forced into a stomach that was herniated up through the diaphragm.


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

  • The stomach anatomy for this plaintiff was far from normal anatomy.
  • The plaintiff’s hiatal hernia was a complex one that could not easily be prevented or corrected with a simple procedure of placement of a nasogastric tube.


 

RESULT:
The jury found in favor of the defense. 

“The exhibits were helpful as this anatomy was so unusual it was difficult to explain it without visual aids. Our co-defense’s client, the surgeon, used one of the diagrams to really help explain to the jury the issues. We received a defense verdict! It was an extremely difficult case with a very experienced plaintiff's counsel. Thanks for your help.”

- Attorney Scott Logan, Logan Logan & Watson, L.C., Prairie Village, KS

 

“Yes, the illustration was indeed helpful. We all received defense verdicts. Thanks for all of your help.”

- Attorney Jayson A. Ford, Shaffer Lombardo Shurin, Kansas City, MO