This case involves a fifty-five-year-old male patient with a past medical history significant for hepatic cirrhosis and liver dysfunction. The patient was admitted to a local hospital for confusion and slurred speech that was attributed to evolving encephalopathy, ascites, and multiple metabolic derangements. The patient received a therapeutic paracentesis to remove excess fluid and was given large doses of Dilaudid for abdominal pain. The patient was found to be unresponsive with minimal spontaneous respirations at which point Narcan was administered; at which time immediate improvement in mental status was noted. The medical records from the hospital note that the patient’s acute change in mental status during the hospitalization was likely due to excess narcotic administration. The patient’s condition worsened after he experienced a severe episode of aspiration of gastric contents that required intubation and a transfer to an ICU setting. After several rounds of hypotensive episodes, chronic hemodialysis and critical care trials the family decided to withdraw pressor support and terminally extubate under palliative care protocol. The endotracheal tube was removed and the patient passed away comfortable within a few hours.

The management of pain in patients with cirrhosis is a clinical challenge for medical professionals as there are not a lot of prospective clinical studies that have offered an evidence-based approach. The reason why patients with cirrhosis experience these complications is because they do not have a functioning liver to metabolize the drug. Thus, the drug accumulates in the blood or in the fat which can add up to lethal doses in the patient. A complication from analgesia in these types of patients include respiratory depression, which can result in even death. In general, acetaminophen at decreased dosages is a better and often safer option. Other options include administering fentanyl or even topical lidocaine patches.

1. Should high doses of opioids have been used in this patient and did this potentially hasten the patient's clinical decline?

Excessive Pain Medication Administered to Patient With Advanced Liver Disease Results in Death

This pain medicine case takes place in Minnesota and involves a patient with cancer of the tonsils. The patient required extensive radiation treatment and was cured of cancer. The patient experienced a great deal of pain as a result of the radiation treatments. The patient’s radiation oncologist prescribed liquid Dilaudid to be self-administered through a PEG tube. The patient was opiate naive and was prescribed the maximum dosage for liquid Dilaudid, 5-10mg every 3 to 6 hours. Sadly, the patient overdosed on Dilaudid on the 2nd day of using the medication and was found dead at his home.

Initiating by prescribing Dilaudid, such as in this case, is a fairly rare practice. I usually prescribe other narcotics first, such as oxycodone 5 mg, every 6 hours as needed. If patients have a bad reaction to oxycodone or morphine, only then do I prescribe Dilaudid. My starting dose of dilaudid is usually 2 mg, every 4-6 hours as needed. To prevent incidents such as the one in this case, I document patient instructions on how to appropriately take and safely store the medication, and also print out these instructions for patients to take home with them. These instructions are specific to narcotic pain medications. In cases in which patients do not respond to a level of narcotic pain medications that I prescribe and require a higher dose than which I am comfortable prescribing, I would then refer them to a pain management expert for further review. Thankfully, I have never had a patient overdose on Dilaudid. This case is very much in my area of expertise.

1. Do you routinely prescribed liquid Dilaudid to patients who've undergone radiation treatment? 2. If so, what precautions are taken to ensure an incident like what's described above doesn't occur? 3. Would you rely on another physician (i.e., palliative care, pain management, hematology / oncology, etc.) to prescribe pain medicine in this instance - or would you prescribe Dilaudid, yourself? 4. Have you ever had a patient overdose on Dilaudid?

Location: Tennessee B.S., Biological Sciences, University of California at Irvine M.D., Northwestern University Medical School Residency, Radiation Oncology, Stanford University Board Certification, Radiation Oncology Member, American Society for Therapeutic Radiology and Oncology Member, American Society of Clinical Oncology Honor, Wilhelm K. Roentgen NCI Award for Research Research, millions of dollars of research funding Published, 73 peer-reviewed journal articles Authored, 25 book chapters Former D******* R*********** P****** V********* U********* M****** C***** Current M****** D******* R******** O******* m**** u********* a********* m****** c***** Current P******** o* R******** O******* m**** u********* a********* m****** c*****

Midwest

Minnesota

This highly qualified Professor o Radiation Oncology received his medical degree from Northwestern University Medical School. He completed a a residency in Radiation Oncology at the highly regarded Stanford University. He is board certified by the American Board of Radiology. This expert has received numerous honor throughout his career including the Wilhelm K. Roentgen NCI Award for Research. He is a member of several professional organizations such as the American Society for Therapeutic Radiology and Oncology and the American Society of Clinical Oncology. He has published 73 peer-reviewed journal articles and authored 25 book chapters.

Cancer Patient Dies from Dilaudid Overdose

This case involves a female patient, a public figure who frequently acted as a reliable notary to multiple agreements, who overdosed on narcotic painkillers and died. She received the pills from the defendant doctor based on a referral from a friend. The patient had no medical records in her possession, and there was no pre-treatment drug screening required or requested. This was the patient’s first visit and the plaintiff alleges that she was there to obtain pain killers as she was a known drug abuser. The defendant failed to perform the minimum physical exam in order to identify, confirm, and document the source of pain other than the patient’s history and complaints. In spite of this, the physician immediately prescribed narcotic pain killers. As a result of the treatment provided by the defending doctor, the patient overdosed and died. The plaintiff alleges that the patient’s conduct was foreseeable and thus, does not excuse a medically trained and licensed doctor from performing the minimum physical exam.

Good care concerning opioid prescribing (there is no difference for us whether it's oxycodone, hydrocodone, morphine, etc) for non-cancer chronic pain includes a thorough history (pain generation, intensity and characteristics, things that exacerbate or improve, timing, previous treatments tried, past medical and surgical history, social history, and review of symptoms, etc.) and physical exam. The physical exam is an important aspect, as it can provide information about other potential undiagnosed comorbidities (obstructive sleep apnea, heart failure, etc.) that could affect a given patient's response to opioids. Also, it significantly adds information that may help treatment decisions; allodynia and hyperpathia suggesting neuropathic pain; motor weakness and muscle atrophy suggestive of a pinched nerve root; and also information that may raise some concern for drug seeking such as exaggerated pain behaviors, give away weakness, non-concordant responses to various tests. Review of additional diagnostic information is also essential (labs, radiographic images, etc.). Non-opioid strategies should be employed first, or at the very least, documented in detail before consideration of opioid therapy. If considered a good candidate, a risk stratification tool should be performed (ORT - opioid risk tool is a set of questions that indicates whether a patient may have a predisposition towards misuse, abuse or addiction. ORT is what I use, but there are others). I would also have a long discussion about risk and benefits, review the state drug database looking for concerning behaviors (multiple prescribers, pharmacies, etc.), assess a urine drug screen and then sign a contract with the patient. It is difficult to adequately define what the bare minimum of a physical exam is. I would say at least a focused exam of the painful area with mention of gross visual inspection, range of motion, tenderness to touch, and any special relevant maneuvers (straight leg raise suggestive of nerve entrapment). It is a breach of the standard of care to fail to adequately perform a physical in advance of prescribing opioids to a new patient. In my clinic, an 18 year old male better have some overwhelming pain condition to justify chronic opioid therapy - it is very rare. As far as determining if a patient is there to obtain drugs for legitimate medical concerns or not, it is often difficult and really an effort at the best informed decision based on the data present. But it is a combination of the data based on the history, risk profile, physical findings, imagining, etc. The reality is that pain medicine is moving away from chronic opioid therapy in general as we have growing evidence that people on relatively high doses of opioid are self-selective based on psychological comorbidities and that when used for common conditions like back pain, they do worse over time. Sometimes it is the only thing that can provide one with a reasonable quality of life, but it should be used after everything else has failed and the patient is appropriately monitored, as even the most conservative and vigilant prescribers of opioids get duped. It's just the reality of the current state of the art.

1. What is the standard procedure before prescribing drugs to patients? 2. What does the minimum physical exam consist of - and is it a breach of the standard of care to fail to adequate perform this in advance of prescribing painkilers to a patient you've never before seen? 3. How do you determine if the patient is there to obtain drugs for legitimate medical concerns or is exhibiting drug-seeking behavior?

Location: Maryland B.A., State University of New York at Stony Brook M.D., Mount Sinai School of Medicine Residency, Anesthesiology, Columbia University Fellowship, Pain Management, Harvard University Board Certified, American Board of Anesthesiology Board Certified, American Board of Anesthesiology - Pain Management Member, American Pain Society Member, American Society of Anesthesiologists Member, American Society of Regional Anesthesia Member, American Society of Interventional Pain Physicians Member, Association of University Anesthesiologists Member, Maryland State Society of Anesthesiologists Published, 80+ peer-reviewed articles, 40+ book chapters Current P******** i*********** S**** C******** S****** I********* t* P***** R************* f** O******** N******** Current P******** D********* o* P******* M******* a** R************* m**** m****** u********* Current P******** D********* o* A************* a** C******* C*** M******* m**** m****** u********* Current D******* o* M****** E******** D******* o* P*** M********* m**** m****** u********* Current D******* o* P*** R******* m**** m****** c***** Current D******* o* C******* O********* P*** M******* m**** m****** c***** Current C**** A********* a** O******** S******* m**** h*******

This double board certified expert has been practicing for 25 years. He obtained his medical degree from the Mount Sinai School of Medicine, completed an Anesthesiology residency at Columbia University, and completed a Pain Management fellowship at Harvard University. Extensively published in the field, he sits on the Editorial Boards of "Pain", "Regional Anesthesia and Pain Medicine", and "Pain Physician", among others, while he is also a member of the Advisory Board of the American Pain Foundation. Currently, this expert is a Professor in the Department of Physical Medicine and Rehabilitation and in the Department of Anesthesiology and Critical Care Medicine at a major medical university. At the same university, he is also the Director of Medical Education in the Pain Management Division. He has received both government and private funding for numerous studies, including three on Radiofrequency for Occipital Neuralgia. He also serves as the Director of Pain Research at a major medical center and the Chief of Anesthesia and Operative Services at another major hospital.

Physician Recklessly Prescribes Painkillers, Contributes to Overdose

This case involves a pair of individuals who were convicted of breaking and entering, along with armed robbery, in relation to a home invasion that took place in the early 1990’s allegedly perpetrated by the plaintiffs. The individuals, who have maintained their innocence since their original conviction, claimed that they were the victims of a police conspiracy framing them for the crime. The plaintiffs alleged that, while they were in the general vicinity of the crime scene shortly after the break-in took place, they did not perpetrate it. The plaintiffs also claimed that evidence used against them during the trial was fabricated by police, that a test such as ink dating would reveal that the police reports were retroactively written, and that an eyewitness to the crime who testified against the men had been coerced or threatened by law enforcement officials in order to provide false testimony that directly contributed to their conviction.

I retired from a State Police department with the rank of major. During my law enforcement career I spent 14 years working in various investigative units. I served as an investigator on an auto theft conspiracy unit, assistant team leader on a narcotics conspiracy unit, commander of a rural narcotics team, and commanding officer of a narcotics task force comprised of several teams across 13 counties. As a commanding officer I was responsible for the judicial integrity of evidence collection, preservation, storage and disposition. As a task force commander I had the responsibility of overseeing an evidence storage room that at times contained millions of dollars in currency, hundreds of pounds of marijuana and several dozen kilograms of cocaine. Never was a piece of evidence misplaced or missed nor were any chain of custody issues identified at court proceedings. As a task force commander and later as a senior commander I was charged with inspecting the evidence management procedures at other investigative units across my state. There were several times where I discovered record and evidence errors that I documented in official inspection reports. As a major I was selected to lead a team that was sent to assist State Police in reviewing and restructuring its investigative and evidence protocol for its drug units after several tragic incidents involving some of those units. My last 18 years in the State Police were in command level positions that required me to be proficient in investigative procedures, protection of evidence procedures and the management of confidential informants. Strict attention was paid to the protocol governing the use of confidential informants. Informants can be a tremendous asset to an investigation but they can also easily be misused. The MSP protocol required the informant and his/her work be documented. It required the presence of two officers for any informant contacts. It required the approval of a commander for payment. And it also required the commander to meet periodically with informants to ensure they understood the use protocol and to determine if the control officers were acting appropriately. Upon assuming the command of the local Police Department I conducted a change of command inventory of all evidence, weapons and records. I found that 23 pieces of seized property were either missing or improperly documented as released or destroyed. I reported this to the city manager in the form of a memo and tried to determine what had happened to the property and by whom. Most items were released or destroyed and improperly documented. This process took nearly two weeks. The previous police chief resigned abruptly when serious allegations of misconduct were made against him. No charges were authorized for the mis-management of the eveidence storage room.Operating outside of policies and procedures certainly calls into question the motives and actions of those involved. If the review calls into question the actions of the officers based on violation of policies and procedures it may be helpful to review a number of other investigations conducted by the defendants. If their actions again violate policies and procedures that may be indicative of malicious intent on their part and/or a serious defect in the supervisory process at the department. I have lectured numerous times at state police and regional law enforcement conferences and training seminars on proper investigative procedures, evidentiary procedures, and confidential informant protocols. I have also lectured to supervisory staff and commanding officers on the processes to use to identify errant behavior whether intentional or not.

1. Please describe your police experience as it relates to crime scene investigation. 2. Would you be able to review the documents of this case and determine whether or not the plaintiffs were wrongly convicted?

Location: MI Former L********* a** T*** F**** C******** G**** R************** S**** P***** Former I******** a** A******** D******* C******** S**** D******* H******************** S**** P***** Former C****** a** D******* C******** S**** D******* H******************** S**** P***** Former M**** a** R****** C******** F**** S******* B************** S**** P***** F****** C**** o* P****** C*** o* L***** M******* P***** D*********

This qualified expert has over 30 years of experience in law enforcement. His expertise includes strong organizational management and extensive knowledge of public safety administrative policies and operational procedures. He previously worked for the Michigan State Police in various positions including Major and Regions Commander of the Field Services Bureau. At the Field Service Bureau, he was responsible for managing quality control and operational direction of all Michigan State Police law enforcement services in Michigan's 83 counties. His most recent position was Chief of Police for the City of Lowell where. in addition to administrative and operational direction, he performed employee performance reviews, investigated alleged employee misconduct, and violations of personnel rules.

Law Enforcement Experts Discuss Allegedly Falsified Evidence in Robbery Conviction

This OR operations case involves a patient in Arizona who underwent a surgical procedure to remove part of his colon. A preoperative workup including a pulmonary and critical care consultation was conducted by the defendant pulmonologist. The consultation revealed that the patient likely had a paralyzed left diaphragm from a workplace accident that occurred many years prior. The defendant recommended deep incentive spirometry. He also recommended that long acting opiates should be limited, and the suggested pain control should be by epidural analgesia to decrease the risk of respiratory depression. On the morning of the surgery the patient underwent a pre-anesthesia assessment. The anticipated anesthetic plan was listed as general. His anesthesia pre-op orders called for him to receive benzodiazepine as well as an opioid pain medication. The patient was taken to the operating room where an additional dose of benzodiazepine was given, and the patient was immediately intubated. Surgery ended and the anesthesiologist noted that the surgeon requested the patient remain on a ventilator. The patient was extubated. Instead of taking the patient to the surgical intensive care unit as ordered the patient was left in the post-anesthesia care unit waiting area. He was later seen by the defendant who observed him to be sleepy. He informed the post-anesthesia care unit staff to be careful about the use of narcotics in the light of the patient’s present clinical situation and past medical history. He was later found to be unresponsive, and was declared dead shortly afterwards.

I treat patients with a similar past medical history on a weekly basis. Deep vein thrombosis prophylaxis is critical, including intermittent compression devices, and consideration for anticoagulation when deemed safe from a surgical perspective. Reduction of narcotics is important but challenging given peri-operative pain; however ketamine may provide analgesia without respiratory depression. Regional anesthesia such as an epidural may also help decrease narcotic use. Post-operative monitoring should include intensive or respiratory-specialized nursing with continuous pulse oximetry and telemetry, as well as consideration of continuous non-invasive capnography. ICU admission is warranted if body mass index is greater than 60 and/or if severe sleep apnea is confirmed or suspected. Consideration of CPAP and/or non-invasive ventilation should also be a component of care if there is evidence of apnea.

1. How often do you treat patients with a similar past medical history to the one described in this case? 2. What measures should be taken pre-operatively, intra-operatively, and post-operatively to ensure the safety of the patients while under anesthesia?

Location: Iowa B.A., Grinnell College M.D., University of Iowa College of Medicine M.S., Program for Biomedical Research, University of Iowa Residency, Internal Medicine, University of Iowa Residency, Chief, Ambulatory Care, University of Iowa Fellow, Pulmonary and Critical Care Medicine, University of Iowa Fellow, Research, University of Iowa Board Certified: American Board of Internal Medicine Board Certified: Pulmonary Disease Board Certified: Critical Care Medicine Published, numerous times on various topics in internal and intensive care medicine Award, Department of Internal Medicine, Award for Excellence in Quality Improvement and Clinical Performance Former A******** P******** I******* M******* U********* o* I******* M******* Former C********** o* M*** U********* o* I*** H***** C*** Current P******** D********* o* I******* M******* a L**** I*** U********* Current M****** D******* M*** a l**** I*** u********* c*** c***** Current M*** a******** a l**** u********* m****** c*** c*****

Southwest

Arizona

This triple board certified pulmonologist has over ten years of experience in Medical Intensive Care Units. He received his medical degree from the University of Iowa College of Medicine, where he also completed his residency in internal medicine. He completed two fellowships, one research and one clinical in Pulmonary and Critical Care Medicine. In his current professorship at a large Iowa university, this doctor lectures on topics such as -˜Sedation, Anesthesia, and Airways in the ICU', and instructs continuing medical education classes for faculty and fellows regarding techniques useful for difficult airways. He is also published over twenty times on various critical care medicine trends and treatments in respected publications such as the American Journal of Respiratory Critical Care Medicine. This doctor has also been invited and asked to publish counterpoints answering questions such as: Should an anesthesiologist be the specialist of choice to manage the difficult airway in the intensive care unit? He has experience in MICUs and VA ICUs as well as specialty experience stemming from a two year clinical assignment as a consultant attending at a Respiratory Specialty Care Unit (RSCU). The RSCU is a unit for adult patients with lung diseases and complex medical problems. Patient populations include: COPD, obstructive sleep apnea, asthma, cystic fibrosis, slow-to-wean ventilator patients, neuro-muscular disorders, and patients who need less than intensive care, but more care than provided on acute medical/surgical units.

Patient is Killed From Depressed Respiratory Function Following Surgery

This case involves a domestic violence victim who was shot and killed by his wife in Kansas. The victim’s wife had a criminal record, and was on probation at the time of the incident in question. On the day of the incident, law enforcement had been called to the couple’s house, where the victim implored officers to provide assistance and stated that he feared for his life. Instead of arresting her, law enforcement left the scene after a few minutes, despite the fact that she was in the house and armed – a violation of her parole agreement. Shortly after the officers left the house, the victim’s wife shot and killed him.

During my 25 plus years of law enforcement experience I held positions as a patrol officer, field training officer, academy training officer, detective in child sex crimes, gang unit, undercover vice/narcotics, sergeant, internal affairs sergeant, detective sergeant, lieutenant, detective lieutenant, motor lieutenant, and have served on a number of administrative Boards of Inquiry investigating the actions of department personnel. I have investigated countless domestic violence incidents, interviewed numerous victims and suspects of domestic violence, and arrested many violent offenders that were armed and unarmed. This is the classic domestic violence call for service where all of the indicators are screaming for the police to take immediate action. The victim had made multiple reports to law enforcement, the suspect was a convicted felon, armed and on probation. Those facts by themselves are sufficient to arrest the wife for being a prohibited possessor, convicted felon in possession of a firearm, which is both a state and a federal offense, (punishable by up to 10-years imprisonment in a federal prison) and clearly violating her probation. There is additional cause to arrest for the death threats against the victim. Given the circumstances and facts of this incident, the death of the victim was predictable and most certainly preventable. The deputies actions, as described, are inexcusable. They are tantamount to malfeasance in office or cowardice and go against the domestic violence training given to law enforcement and the laws enacted by state legislatures specifically to protect victims of domestic violence.

1. Please describe your experience in law enforcement as it relates to domestic violence calls. 2. How often do you serve domestic violence protection orders? 3. What are the proper protocols that should be in place when responding to a domestic violence call?

Location: AZ BS, Business Administration, University of Charleston Member, Fraternal Order of Police Member, International Law Enforcement Educators & Trainer's Association Former D******** T***** P***** D********* Former S******* T***** P***** D********* Former L********* T***** P***** D********* Former P****** C********** A* G********** O***** o* H****** S***** Owner, a Spanish language training program from public safety personnel

Kansas

This expert has over 30 years experience with the Tuscan Police Department. He began his career as an Officer before holding titles such asDetective, Sergent, and Lieutenant. Within his time there he received numerous awards including the Medal of Valor, Medal of Merit, and Public Service Excellence Award. He has managed over 100 officers and has experience in a variety of facets of the police force. He is currently a Spanish language translator and instructor for public service personnel.

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Narcotics Expert Witness Case Studies

Excessive Pain Medication Administered to Patient With Advanced Liver Disease Results in Death

Cancer Patient Dies from Dilaudid Overdose

Physician Recklessly Prescribes Painkillers, Contributes to Overdose

Law Enforcement Experts Discuss Allegedly Falsified Evidence in Robbery Conviction

Patient is Killed From Depressed Respiratory Function Following Surgery

Law Enforcement Expert Opines on Mismanaged Domestic Violence Incident

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