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
Delay in Diagnosis of Tongue Cancer

The patient, a 42-year-old woman, was referred by her prosthodontist (dentistry that focuses on dental prostheses) to an oral surgeon for assessment of a lesion on her tongue that she said had been present for 4-6 weeks. On examination, he noted that the most likely diagnosis was a traumatic lesion and treated it with saline rinses and antibiotics. Because the patient was a smoker, he informed her that a biopsy to rule out cancer might become necessary if the lesion did not improve with the initial treatment. Over the next two weeks, she had two follow-up visits with the oral surgeon. At the first appointment the condition of the lesion had improved, and at the second appointment it was unchanged. Over the following three weeks, she had three more visits to her prosthodontist, who prepared a partial lower denture and realigned her full upper denture.

Approximately a year and a half later, she presented to a new dentist with complaints of severe mouth pain. The dentist diagnosed and treated her for candidiasis (a fungal infection). One month after that, the dentist referred her to her original oral surgeon for a biopsy of her tongue. The oral surgeon performed her biopsy the same day, and one week later, the biopsy resulted in a diagnosis of squamous cell carcinoma. She was then referred to another doctor who evaluated her and treated her oral cancer with chemotherapy and radiation. She ended up with a permanent G-tube (gastrostomy tube), lost all of her teeth, and developed impaired saliva glands.

 

PLAINTIFF'S CLAIM:

The defendant (the oral surgeon) was negligent in his treatment of the plaintiff when she first presented to him with a sore on her tongue. Specifically, the defendant should have, but did not, biopsy the lesion, which would have shown that she had oral cancer. Had she been diagnosed at this time, she could have been treated with surgery and likely would not have needed a G-tube. Also, she would have had a greater than 50 percent chance of avoiding radiation and its attendant side effects. She could have led a normal life. Instead, the delay in diagnosis resulted in chemotherapy and radiation treatment, because of which she had a permanent G-tube placed to take nutrition, she lost all of her teeth, and her saliva glands became impaired. As a result, she could not eat normally and she could not work. She suffered economic loss due to her inability to work, and her son, who was 11 years old at her time of diagnosis, suffered loss of parental society.

 

 

DEFENSE'S ARGUMENT:

The lesion that the plaintiff originally presented with lined up exactly next to tooth #20, which was jagged and stuck out by itself, because the adjoining teeth (#s 19 and 21) were missing. The defendant thus believed the lesion was a traumatic injury due to her biting in that area, and not a carcinoma, especially since the tooth and the lesion lined up so exactly. The standard of care with a lesion of this type is to watch and see if it gets better, which it did initially in this case. The plaintiff skipped a 4th follow-up appointment that she had scheduled with the defendant. It was not until a year and a half after her 2nd and 3rd visits with the defendant, in which her condition had improved then remained unchanged, that she had her final visit with him, at which time she was biopsied and diagnosed with squamous cell carcinoma. She remains free of any recurrent disease associated in any way with her tongue cancer and has never had any metastatic disease from this cancer. The standard of care was complied with at all times during treatment.




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.

 

We began with a timeline of events to demonstrate the dates of the plaintiff’s visits to healthcare providers from the time of her initial presentation to the time of her biopsy, including the length of time between her last visit with the defendant before she was biopsied.

 

The second and third diagrams were created to illustrate the location of the tongue ulceration and the appearance of the tongue ulceration when the plaintiff first presented to the defendant, including the location of her missing teeth.

 

Next, we put together two studies of the plaintiff’s pathology slides at the time of biopsy (One and Two), as well as examples of pathology slides showing normal grade 1 (well-differentiated), grade 2, and grade 3 carcinoma.

 

We then created a cancer doubling time chart and timeline to illustrate the growth rate of the carcinoma over time, as well as a supporting diagram of tumor doubling time.

 

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

  • The location, size and, appearance of the tongue lesion was so perfectly aligned with the anatomy of the plaintiff’s teeth that it was appropriate for the defendant to believe this was a traumatic lesion, especially in light of the plaintiff’s statements that she had bitten the area. It was within the standard of care to treat it as such, watch the lesion to see if it got better, and to take further action if it did not improve.
  • A year and a half passed between the plaintiff’s last follow-up visit with the defendant and the visit where her tongue was biopsied and she was ultimately diagnosed with squamous cell carcinoma. During this period, she had scheduled but skipped an additional follow-up visit, because as she reported, her symptoms had resolved. At no time during this period were there any further complaints by the plaintiff of any issues with her tongue.

 

RESULT:
The jury found in favor of the defense. 

“We want to thank you so very much for your patience, assistance and talent in creating the boards and illustrations for this trial. We were very pleased to receive a defense verdict yesterday. We found the boards (especially the illustration of the ulcer on the tongue, and the doubling time graph) to be very important and helpful. We look forward to working with you again soon.”

- Attorney Ellen E. Cohen, Adler, Cohen, Harvey, Wakeman and Guekgeuzian, L.L.P., Boston, MA