Expert Witness Blog

Pulmonary medicine expert witness Kathleen S. Adams, RCP, RRT-NPS, is an instructor and owner of Packmule Education & Consulting Services in Southern California. Also the president-elect of the California Society for Respiratory Care, here she writes on difficult airways.

What constitutes a difficult airway? It is important to have an understanding of this and particularly what is causing the airway difficulties that you are experiencing in order to better understand which Plan B may be your best option. There is however, no single generally accepted definition of a difficult airway. For the purposes of its practice guidelines for the difficult airway, the American Society of Anesthesiology set a definition of a clinical situation in which a conventionally trained anesthesiologist experiences difficulty with face mask ventilation of the upper airway, difficulty with tracheal intubation, or both. The guidelines continue that an airway proven to be difficult is a combination of patient factors, the current clinical setting and the skill level of the practitioner performing the airway maneuvers.

This article appears in RT for Decision Makers Magazine March 2009.

In Clinical Standards in Medicine medical expert witness Barry E. Gustin, MD, MPH, FAAEM, writes:

For each of these rules, there are corresponding guidelines which may or may not be appropriate to act on. For example, under character of pain, it may or may not be useful to ask about the onset of the pain, the severity, the location, whether radiation occurs, its frequency, duration, similar previous episodes, precipitating or mitigating factors, its relationship to exertion, rest, movement or deep breathing and so on. It is clear to physicians that although this information is relevant for many patients presenting with chest pain, there are times when this information does not apply and has no real utility, such as the young otherwise healthy patient with fever who complains of chest pain only when coughing.

Similarly, there are no absolutes about what constitutes appropriate adherence to the guidelines for physical examination. A physician may decide, based on the overall clinical picture of the patient, to listen to the lungs, percuss the lungs, X-ray the lungs, assess the oxygenation of the lungs by doing pulse oximetry or arterial blood gases and so on. It would be left up to the physician to decide whether these things were or were not appropriate to do.

Leading brain injury expert Dr. Neil Martin of UCLA Medical Center says that even falling from a standing position is “a six-foot fall as far as your head is concerned” and that relatively minor accidents can prove fatal.

The first three hours following the onset of a critical health episode like a stroke are critical. If care is delayed beyond this critical time window, the chance of recovery or even survival declines substantially. Much of the first hour following the onset of these critical episodes is spent simply getting the patient to the emergency room. Then the patient must then be diagnosed, CT and MRI images and scans taken and developed. Finally, a specially trained physician must review the images and make a decision on the appropriate treatment protocol.

Dr. Martin is Founder/CEO of Global Care Quest and Chief of Neurosurgery at UCLA Medical Center. His company has developed a new wireless mobile technology that allows physicians to view CT and MRI images and scans from remote locations. This solution, ICIS Mobile, transmits images over high speed wireless networks to a physician’s cell phone or PDA.

Texas SB 362 which deals with voter identification has cleared the Texas Senate and will be sent to the Texas House. SB 362 will create a more secure election process and strive to ensure elderly and low income Texans who are eligible to vote are able to do so with minimal difficulty.

Bill Noble, a spokesman for SAFE Texas, a coalition of Texans dedicated to ensuring security and fairness in the election process, stated that fraud investigation expert witnesses supporting the bill demonstrated the difficulty in detecting and deterring voting fraud under the current system. “SB 362 is a major step forward in helping to detect and deter election fraud and assure Texas elections are secure and fair.”

In Clinical Standards in Medicine medical expert witness Barry E. Gustin, MD, MPH, FAAEM, writes:

One of the first clinical problems targeted for standards development was Chest Pain. As a prototypic example of clinical policy development, the Specialty Board responsible for the development and implementation of this standard created three conceptual entities which can be applied to all clinical problems. They are “actions”, “variables”, and “findings”.

Actions are defined as either “rules” (principles of good practice in most situations) such as ordering an electrocardiogram on an elderly patient with shortness of breath and severe chest pain, or “guidelines” (actions that should be considered but may or may not be performed depending on the patient, the circumstances, and a multitude of other factors) such as ordering imaging studies on any patient with chest pain. In those situations where a rule isn’t followed, the physician would be required to document in writing his justification for its avoidance.

In Clinical Standards in Medicine medical expert witness Barry E. Gustin, MD, MPH, FAAEM, writes:

Potential limitations should be recognized and dealt with such as the possibility that a particular standard becomes obsolete because of new discoveries or advances; or situations where environmental factors such as disaster, overcrowding, or multiple high acuity emergencies negate the applicability of standard clinical policies. Likewise, policy standards can never supersede the physician’s clinical judgement which must be taken as the final word in making patient care decisions. This is because of the immense number of clinical variables and continually changing circumstances in both stable and unstable patients with complex multifactorial systemic medical problems.

For maximum effectiveness and utility, it is clear that standards should be developed in the areas that place the patient at highest risk for death or debility. For the physician, these are often the areas of greatest liability. Also, it is important that standards are developed for common presenting complaints rather than for obscure uncommon entities. Finally, because cost-containment has become a central issue, clinical standards should also target those conditions or situations that may result in high charges.

In Clinical Standards in Medicine medical expert witness Barry E. Gustin, MD, MPH, FAAEM, writes:

The existence of clinical standards would enable malpractice litigators to be more selective in their choice of cases. In situations where a clinical standard was followed but where there was an adverse patient outcome, litigators would be less inclined to pursue the matter. In situations where deviation from clinical standards, the litigation process would still allow physicians to explain their reasoning and, in and of itself, is not de facto proof of negligence.

The actual development of clinical standards is complex, time consuming and expensive. In general, these standards should be developed by physician organizations, particularly the specialty societies utilizing appropriate ancillary input from administrators, economists, etc. They should be based on current information and clinical experience and be as comprehensive and specific as possible. They should be periodically reviewed and revised and widely disseminated.