Ruptured appendix leads to permanent brain injury - $3.2M jury award

Illustrated Medicine: Case Study

Delayed appendicitis treatment causes hypoxic brain injury – $3.2M jury award

Incident
This 11-year-old boy with Down Syndrome suffered a ruptured appendix from delayed diagnosis and surgery, leading to unrecognized septic shock that triggered cardiopulmonary arrest, resulting in hypoxic brain injury.

Purpose of illustration
This illustration panel was created for use as an introductory exhibit, to demonstrate normal anatomy of the appendix and the pathology of early appendicitis versus Jason’s subsequent ruptured appendix with extensive ascites in his abdomen – as seen on CT.

Rationale for litigation visual
The exhibit allowed the jury to clearly understand the difference between early diagnosis of appendicitis and treating it initially, versus the significant abdominal pathology that resulted from rupture of the appendix due to delayed treatment.

Complications
Initially treated with antibiotics and a drain, he later underwent an appendectomy (which revealed interim abscess formation). The delay in surgery triggered cardiopulmonary arrest due to septic complications affecting his pacemaker wires, with a lengthy period of anoxia resulting in permanent brain injury.

Other visuals demonstrated
Additional exhibits included a series of comprehensive interactive timelines, as well as illustrations of the client’s anoxic brain injury issues.

Outcome
Prior to trial there was no settlement offer made by the defendants. The jury reached a $3.2 million verdict.

“Throughout the trial, the use of demonstrative exhibits prepared by Artery Studios was invaluable in educating the jury about the many complicated medical issues as well as the long timeline involved in this case. The exhibits and timelines prepared by Artery Studios aided us in telling our client’s story to the jury, and we believe these exhibits were instrumental in the positive result for our client.” 

– Gena Romagnoli, Henry Phillip Gruss Ltd


Remote Control - Part 2

REMOTE CONTROL – Part 2

More tips for maximizing success in online mediations

In Part 1 we discussed office configuration, lighting, internet speed, and using PowerPoint to integrate photos into your video-conferenced mediations. Let’s explore how visual communications can further enhance your negotiations.

Capitalize on show-and-tell
Don’t make the mistake of being a talking head, orating about your client’s issues while eyelids grow heavy. As your comfort level with the online experience increases, up the impact of your presentations by inserting medical illustrations, animation clips, video footage, timelines, etc. As we all know, a digital interface isn’t as up-close-and-personal as meeting face-to-face, so using visuals to engage others, while explaining the complex medical facts of a file, creates a richer connection. Medical illustrations will catch and hold attention and put you firmly in the position of being the source for relevant and reliable information.

Keep all eyes on the ball – your client
One potential pitfall of video conferencing is that your client can appear postage stamp sized on screen – a problem when you want the session to be all about them. To ensure everyone keeps focused on the heart of the matter, include a photo of your client, and their name, on each of your slides. This provides a constant visual reminder of “Mr. Smith” and his trauma issues.

Tell me a story
Visual storytelling allows for not only an enhanced emotional appeal, but also provides a path for others to follow along. Visuals should be kept simple, with each slide showing one clear concept. Make the slides build on each other, telling the story one ‘paragraph’ at a time. Educational researchers refer to this as scaffolding (Pea, 2004). A presentation that builds will show the full arc of your client’s story, demonstrating evolving trauma issues, surgical procedures, or deterioration issues, in a step-by-step manner that will vividly communicate what they had to endure.

Knock it out of the park
Wrap up your client’s story with an overview chart or full-figure illustration that drives home their injury complications. Summary visuals combined with before and after photos will leave a lasting impression that’ll maximize outcomes and help resolve the file successfully.

We hope these tips will invigorate your mediations to help you get the most from your online negotiations.

Reference: Pea, R., & Mills. (2004). The Social and Technological Dimensions of Scaffolding and Related TheoreticalConcepts for Learning, Education, and Human Activity. The Journal of the Learning Sciences, 13(3).


Remote Control - Part 1

REMOTE CONTROL – Part 1

Tips for maximizing success in online mediations

So, you’re working remotely and conducting mediations for PI files. How do you make an impact when everyone’s not in the same room? Here are some reminders for making your Zoom zing!

1 – The Camera Never Lies
We all do it – forget about the too-bright window behind you or vase of wilted flowers. First thing is to make your background look great. Rearrange your home office to show off your diplomas, a bookcase of legal tomes, maybe an anatomical model – whatever it takes to telegraph that you’re a serious and professionally-grounded PI litigator. Oh, and remember that your camera may be hi-res – so lipstick on your teeth or stubble on your chin may be clearly in focus to others!

2 – Say What? 
Despite so much current online interfacing, garbled voices continue to be a recurring frustration for all. University students note that audio is the most important factor in effective online learning1. Since remote engagements are here for a while, it’s likely time to invest in a USB-plugin microphone that’ll make others hang on your every word – often for less than a hundred dollars. A headset with mic is okay, but you risk looking like a radio-host!

3 – At the Speed of Light 
If you’re working from home or the cabin, now’s the time to upgrade your internet, so your engagement is crisp, without lags or the dreaded frozen screen. This may entail a new router, hooking up WiFi repeaters, or running a direct-wire internet cable to a newly-created workspace. But the investment is priceless for making your mediations unfold as smooth as silk.

4 – Lights – camera – action 
Professional video bloggers (vloggers) use lighting tricks – and so should you. There are many light fixtures available that’ll cast you in a warm glow and make you clearly visible. A simple solution is a desk lamp with a 40W incandescent bulb (or LED in the 2,700-3,000 Kelvin range) shining towards you from the far side of your screen. Good lighting will make you look fresh, confident and in control.

5 – A picture of health (NOT…)
Video-conference platforms (like Zoom), cry out for visual storytelling. When you have the floor (screen), take control of the session in “presenter” mode, and hold attention by using visuals. They’ll keep your presentation on track and keep everyone focused on the key issues. Use before/after photos of your client, highlighted report excerpts, or shots of the vehicle damage. Once you get comfortable sharing your screen in mediation settings, take it up a notch with more advanced visuals that maximize outcomes – we’ll cover that in Part 2, so stay online…

(1) Findings from informal survey of University of Toronto graduate students in Biomedical Communications.


Rollover Causes Chest Trauma with Cardiac Arrest

Illustrated Medicine: Case Study

Rollover Causes Chest Trauma with Cardiac Arrest

Incident 
This 28-year-old passenger suffered multiple injuries from a rear-end collision that caused the vehicle she was into rollover and hit a pole. 

Purpose of illustration 
This exhibit was created to demonstrate Ms. Jones’s later internal chest trauma – namely, complete collapse of the middle and lower lobes of her lung, with blood filling 70% of the right chest cavity (hemithorax) and pushing against her heart. 

Rationale for litigation visual 
Although CT scans demonstrated the chest pathology to medical professionals, non-medically-trained litigation participants needed a visual ‘translation’ of the films and case reports, thereby allowing everyone to appreciate the severity of this trauma. 

Complications 
Ms. Jones underwent a thoracotomy to remove the large volume of blood from her chest. She then suffered cardiac arrest and an emergency sternotomy was performed to evacuate blood from the pleural space and to insert chest tubes. Bleeding from the innominate artery was discovered and ligated after sharp pieces of fractured clavicle and rib were removed. 

Other visuals demonstrated 
Additional illustrations depicted: multiple rib fractures causing ‘flail chest’; spinal, right clavicular and scapular fractures; and details of three chest surgeries that were performed. Complications of scapular winging and reduced shoulder mobility due to right thoracic nerve injury, as well as thoracic outlet syndrome, were also demonstrated. 

Outcome 
A significant settlement was reached just days before the trial was to commence.


Spinal Fusion from Dump Truck Rear-Ender

Illustrated Medicine: Case Study

Spinal Fusion from Dump Truck Rear-Ender

Incident 
This 50-year-old driver sustained significant injury when his vehicle was rear-ended by a dump truck, causing trauma to his cervical spine. 

Purpose of illustration 
This exhibit was created to demonstrate the appearance of his spine after it was surgically fused, providing a clear translation of the imaging and medical reports, including showing the bone grafts that were inserted to replace the bulging discs that were removed – details that were difficult to appreciate on x-rays. 

Rationale for litigation visual 
For those untrained in medicine, this illustration provides clarity for the complex surgery performed and hard-to-understand radiologically. It provides a concise view of what took place in the OR – showing the anterior plate affixed with screws to the vertebrae, the associated bone grafts and the incision. 

Other visuals demonstrated 
Additional panels illustrated the post-MVA pathology of Mr. Doe’s cervical disc bulges impinging his spinal canal, and the surgery that was required to reposition his symptomatic left ulnar nerve. 

Outcome 
Adam Starr of Jarve Kaplan Granato Starr LLC, used the exhibits at mediation to clearly communicate the key details of his client’s spinal pathology and required surgeries performed, securing a high six-figure settlement for his client.


Trucking Accident Triggers Stroke

Illustrated Medicine: Case Study

Trucking Accident Triggers Stroke

Incident 
This 53-year-old driver was hit by a truck twice – his car first spun and was then pinned against the concrete median – subjecting him to rotational, acceleration and deceleration forces. 

Purpose of illustration 
Designed to show how injury to his vertebral artery caused stroke damage to areas of his brain, this panel included details of: anatomy (arterial and cranial); physiology (bloodflow and thrombus formation); and pathology (ischemic damage). 

Rationale for litigation visual 
This illustration exhibit was required to allow litigation participants to connect the initial physical injury to the artery in Mr. Doe’s neck, with the resultant ischemic (stroke) damage in his brain – complex factors for most non-medically trained people to understand. 

Complications 
Due to instability in his upper cervical spine, he was prone to recurring transient ischemia, reducing the blood supply to his brain, causing him neurological problems. 

Other visuals demonstrated 
Additional illustrations showed other trauma issues of: exacerbation of pre-exisiting findings; double-crush syndrome in his upper limbs; cervical radiculopathy; rotator cuff syndrome; chronic pain, including neck, back, shoulder and leg pain; and possible future spinal surgery. 

Outcome 
The case settled very successfully as trial was about to begin. 

 


Shoulder Injury from Head-on Collision

Illustrated Medicine: Case Study

Shoulder Injury From Head-on Collision

Incident
This left-handed 56-year-old driver was involved in a head-on collision, causing soft tissue damage to her left shoulder as well as other injuries.

Purpose of illustration
This panel was created to show the mechanism of injury to her AC joint and supraspinatus tendon, resulting from a significant seatbelt force being suddenly applied to her shoulder during impact.

Rationale for litigation visual
The transmission of forces from the shoulder belt, to the clavicle and thereby to the bones and tissues of the shoulder, were key concepts to be communicated at trial. The illustration served to ‘translate’ the opinion of the biomedical engineer into a visual format, allowing for clear understanding.

Complications
Ms. May went on to experience persistent pain in her shoulder, reflecting the effects of inflammation and scarring of tendons, ligaments and bursa, with secondary mechanical effects.

Other visuals demonstrated
Additional illustrations showed more detailed findings of the shoulder pathology, as well as left knee injury concepts.

Outcome
Plaintiff’s lawyer, Norma Mayer, opined that “…the illustration was instrumental in resolving the file at mediation.”


Trauma-Induced Sciatica

Illustrated Medicine: Case Study

Trauma-induced sciatica

Incident
This 50 year-old seat-belted driver was rear-ended at highway speeds. He suffered a lumbar spine sprain/strain injury.

Purpose of illustration
This illustration exhibit was created to demonstrate the direct anatomical link between the trauma-induced L4-5 disc herniation diagnosed post-accident, and the resultant painful sciatica symptoms of shooting burning pain into his buttock and down his leg, making it difficult to stand and walk.

Rationale for litigation exhibit
Mr. Smith had previous surgery in this area and was susceptible to further injury. The jury needed to appreciate: details of the injured disc with herniation resulting from the impact forces; associated impingement of the L4 nerve root component of the sciatic nerve; and the resultant pain that radiated through his lower back and into his left lower limb in the L4 dermatome pattern.

Complications
The L4-5 disc underwent further degenerative changes. Mr. Smith had several injections for pain, and surgery was eventually required.

Other visuals demonstrated 
Additional illustrations showed: details of the mechanism of injury; an overview of how disc herniation progresses to the point of nerve root impingement; and the associated decompression surgery that was performed.

Outcome
The case settled immediately before trial was to begin.


Trimalleolar Fracture-Dislocation

Illustrated Medicine: Case Study

Trimalleolar Fracture-Dislocation

Incident
This 21-year-old construction worker slipped into a hole, sustaining a displaced/dislocated trimalleolar fracture that required open reduction internal fixation (ORIF). Osteoarthritis (OA) developed quickly in the joint due to the impact to, and disruption of, the articular cartilage.

Purpose of illustration
This panel was created to demonstrate the significant fracture-dislocation with associated injury to the syndesmosis (the distal tibia-fibula joint bound together by ligaments). The illustrations allowed litigation participants to fully appreciate the severity of the trauma and why OA ensued.

Rationale for litigation visual
Although x-rays demonstrated the fracture-dislocation, illustrations were required to translate the films into more readily understood images to show the full extent of trauma, including details of the syndesmosis injury.

Complications
Post-injury, this young man suffered pain on ambulation and at rest. His ankle joint demonstrated osteoarthritic degeneration within a year of the slip & fall. Some of the hardware and osteophytes required surgical removal. Further degeneration and associated surgeries were predicted for him.

Other visuals
Additional illustrations showed: the post-op appearance after ORIF surgery; hardware removal; future further osteoarthritic degeneration; and potential future ankle surgery – including debridement, fusion or replacement.

Outcome
This exhibit was created to allow the orthopedic expert to fully explain the extent of trauma this man sustained, and the significance of his intra-articular fractures. The illustrations were sent to defense and the case settled before trial.

 


Intra-Articular Wrist Fracture

Illustrated Medicine: Case Study

Intra-Articular Wrist Fracture

Incident 
Mr. Jones was a 45-yo male driver involved in a head-on collision and required extrication. 

Purpose of Illustration 
This panel was created to show details of his left wrist injury, providing a visual translation of the radiology and medical reports. It also served to demonstrate the severity of the trauma-related issue(s), to address objections of pre-existing psoriatic arthritis and two prior MVA’s with unrelated sequelae. 

Rationale for litigation visual 
X-rays were too difficult for a jury to comprehend understand. Other visuals showed the surgery performed and degeneration concepts resulting from the significant damage he sustained to the articular cartilage in his wrist. 

Complications 
He was later shown to have early arthritic changes in his left wrist joints – based on x-ray findings and a bone scan. Experts opined that his wrist would likely continue to degenerate with osteoarthritis. 

Other visuals demonstrated 
Concepts of: concussion; lumbar spine injury/surgery; pain treatments; sciatica complications; and right foot issues including fractures, surgeries, and degeneration. A 3D-printed model showed details of his right foot fractures. 

Outcome 
The demonstrative evidence was created in time for mediation. Using the visuals, the lawyer walked through the medical issues in detail, linking them directly to the biomechanical engineering opinions. A significant settlement was reached shortly thereafter with the visuals showing the clear “facts” and informing the adjuster’s decision.