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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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
Diverticulitis Surgical Interventions
Lead to Complications

In 2008, a post-hysterectomy woman in her mid-60s presented to the emergency room with fever, general malaise, and weakness. She had been diagnosed with diverticulitis in the past, and at the time, surgery had been discussed as a possible treatment to prevent future problems, but ultimately she had been treated conservatively with suggested changes in diet. During her 2008 visit to the ER, however, it was determined that her symptoms were caused by a diverticulitis flare-up. The determination was made that, along with antibiotic treatment, surgical intervention would be the best course of action.

Because of the infection caused by the diverticulitis, performing a one-stage procedure, as discussed at the patient’s original diagnosis, was considered unwise. Instead, her surgeries would be done in two stages, the first being a sigmoid colectomy (left hemicolectomy) with temporary ostomy until her inflammation was gone, at which point the second surgery would reverse the colostomy and reconnect the colon to the rectum (anastomosis). During the first procedure, in August of 2008, the surgeon discovered abscesses and infection in the abdomen, as well as in the colon. In January of 2009, the patient underwent the second procedure to take down the colostomy and create a side-to-end coloproctostomy. Approximately two-and-a-half weeks after the second procedure, the plaintiff had a follow-up visit with the surgeon in which she stated she was doing fine.

Following this visit, the plaintiff discovered that she was passing gas vaginally and had fecal matter coming out of her vagina. She was subsequently diagnosed with rectovaginal fistula. In the course of two subsequent procedures, the surgeon discovered seven or eight staples in the vaginal wall. The plaintiff ended up undergoing seven total surgeries, suffered multiple hernias, and had an ileostomy for over a year.

 

PLAINTIFF'S CLAIM:

During the second procedure (takedown of colostomy with coloproctostomy), there was vaginal tissue in the anastomotic line when the stapler was fired.

 

DEFENSE'S ARGUMENT:

Over two weeks passed between the second surgical procedure and the plaintiff's first complaints of passing gas and fecal matter vaginally. If vaginal tissue had been involved in the anastomosis at the time of surgery, the patient's symptoms would have appeared much sooner than two weeks after the surgery. Additionally, the air test performed at the time of the colostomy reversal not only would not have turned out normal, which it did, but it would not have been able to be performed at all. Over time following the coloproctostomy, a leak formed at the anastomotic site and an abscess developed. The body's natural response is to get rid of infection, so the abscess eroded and created a hole (fistula) into the vagina, so the infection could be expelled from the body through the vagina. As part of this process, the staples from the anastomosis were migrated into the vagina by force.


VISUAL STRATEGY:

Collaborating with the defense attorneys, Illustrated Verdict created a visual strategy to help explain the steps taken in the care of the plaintiff, supporting the view that the defendants' actions were within the standard of care.

 

The initial diagram illustrated diverticulitis as was present in the plaintiff prior to surgery.

 

The second diagram illustrated perforation of diverticulum with abscess, which caused the infection in the plaintiff’s body and the symptoms she presented to the ER with, prompting surgical intervention.

 

The next two diagrams illustrated the initial procedure in August 2008 to resect the affected portion of the colon and create a temporary ostomy.

 

The next sequence of diagrams illustrated the second surgical procedure, from January 2009. The first two illustrated the colostomy reversal and side-to-end anastomosis. The next diagram showed a proctoscope being used to insufflate the site of the anastomosis as an air test to ensure no leaks were present. In addition, a diagram was created to illustrate the end result of this surgery from different views, showing the locations of all relevant anatomy in relation to each other, including a cross-sectional view of the ring of staples in the side-to-end anastomosis

 

The next two diagrams were created to illustrate the defense’s theory. The first broke down how a leak formed at the site of the anastomosis, an abscess formed, a rectovaginal fistula formed, and peristalsis (muscular contractions) propelled fecal matter through the digestive tract, through the fistula, and into the vagina, causing the staples to migrate into the vagina by force. The second diagrams showed a detailed view of this: the vagina laying on top of the rectum, the colon anastomosis breaking down, and one to two staples crossing over and moving into the vaginal wall, which then fused to the staples.

 

Finally, an eleventh diagram was created to show the process of inflamed tissue healing over a staple.

 

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

  • The defendants treated the patient’s diverticulitis flare-up appropriately by deciding on a 2-stage procedure, given the inflammation in her body when she presented to the ER.
  • The defendants worked within the standard of care during the first and second surgical procedures, and specifically during the second procedure, by performing the air test to ensure that there were no leaks at the anastomosis, which there were not.
  • The patient was stable throughout and after both procedures, including at a follow-up visit more than two weeks after the second procedure, at which the patient stated she was doing fine.

 

RESULT:
The jury found in favor of the defense. 

“We obtained a defense verdict. The illustrations were of great assistance. This was especially true in light of the fact that plaintiff did not use any demonstrative evidence. I believe the illustrations were key in communicating our theory of the case. Thanks for all your help.”

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