This case involves a 5-year-old female who presented to the ER with abdominal pain. She had a past medical history significant for developmental delay and required an intravenous total parenteral nutrition feeding tube placement (TPN) several months prior. The patient was admitted for observation, x-rays were ordered but the interpretation of imaging at this time was abdominal pain due to constipation and the patient was discharged. The following day the patient returned to the hospital with increasing pain and at this time abdominal imaging studies revealed a dilated intestine with possible perforation. The patient was brought into surgery and a volvulus was discovered to be the cause of the pain. According to the medical records, the patient experienced a prolonged lack of blood supply to the abdominal viscera and subsequently sustained a significant amount of bowel necrosis. The patient could not be weaned off the ventilator post operatively and the family decided to withdraw life support shortly thereafter.

I can say with a great deal of certainty that this patient would have benefited from a timely diagnosis and prompt institution of surgical intervention. In any field it is the physician's duty to rule out any life threatening causes of illness before adopting an observation approach and it seems more aggressive care was warranted here.

The issue is whether the CT scan would have revealed the volvulus immediately and would this have made a difference in the outcome of the surgery had it been performed sooner?

Location: New York B.A., University of California at Berkeley Ph.D., University of California at Santa Barbara M.D., University of California at San Diego Internship, Pediatrics, University of California at San Francisco Residency, Pediatrics, University of California at San Francisco Fellowship, Pediatric Gastroenterology, Hepatology & Nutrition, University of California at San Francisco Board Certification: Pediatrics, Gastroenterology and Nutrition, Transplant Hepatology Member, American Gastroenterological Association Member, North American Society for Pediatric Gastroenterology Member, American Liver Foundation Member, American Academy of Pediatrics Former A******** P******** P********* U********* o* C********* a* S** F******** Former A******** P******** P********* H****** M****** S***** Former A******** P******** P********* U********* o* C********* a* S** D**** Former P******** C******* P********* U********* o* C********* a* S** D**** Former V************ P********* U********* o* C********* a* S** D**** Former P******** P********* U********* o* C********* a* S** D**** Former A******** P******** U********* o* C********* a* S** F******** M****** C***** Former D******* L**** R******* T** C********** H******* a* B***** Former C**** G*************** H********* a** N******** P********* U********* o* C********* a* S** D**** Current D******* D******* / A******** S**** M***** S****** C********** H******* Current C**** P******** G*************** T** T** M****** S***** H******* Current P******** P********* T** T** M****** S*****

This expert is board certified in Pediatrics and has additional fellowship training in Pediatric Gastroenterology. He was the former Chairman of Pediatrics at the UCLA San Diego Medical Campus and currently is the Chief of Gastroenterology at a prestigious Medical Institution in New York City.

Untimely Diagnosis of a Bowel Obstruction and Delay in Surgical Intervention Leads to 5-Year-Old Child’s Death

This OR operations case involves a fifty-eight-year-old female patient who presented to the ER complaining of multiple episodes of daily, non-bilious, non-bloody vomiting, along with generalized abdominal pain. The patient was diagnosed with an intestinal obstruction and was taken to the operating room, where a sigmoidal mass was identified to be obstructing the entire lumen of the bowel. A hemicolectomy with colostomy and mobilization of hepatic flexure was performed. One week after surgery, the patient developed abdominal compartment syndrome and was brought back to the operating room for exploration. The patient sustained a cardiac event on the operating table and CPR was conducted. The patient remained ventilator dependent secondary to respiratory failure, along with acute renal failure that necessitated peritoneal dialysis. The patient never regained consciousness following the exploratory abdominal procedure and the family decided to withdraw supportive care after two weeks.

If left untreated for an extended time, abdominal compartment syndrome is almost uniformly fatal. Eddy and colleagues documented a mortality rate of 68% for patients with documented abdominal compartment syndrome seen from 1984-1996. Most of the population was male (70%), and most had experienced blunt trauma (80%). In the subsequent literature, mortality rates have ranged from 25%-75%. The high mortality in abdominal compartment syndrome, even with treatment, reflects the fact that the condition affects multiple organ systems. Furthermore, abdominal compartment syndrome is often a sequelae to severe injuries that independently carry a high morbidity and high mortality.

1. What is the general prognosis for abdominal compartment syndrome?

Location: Iowa B.S., Nebraska Wesleyan University M.D., University of Minnesota Medical School Residency, General Surgery, University of Minnesota Medical School Fellowship, Surgical Infectious Diseases, University of Minnesota Hospitals and Clinics Fellowship, Colon and Rectal Surgery, University of Texas Affiliated Hospitals Board Certification: Surgery; Colon and Rectal Surgery Member, American College of Surgeons Member, American Society of Colon and Rectal Surgeons Former A******** P******** S****** U********* o* S**** F****** Former C**** C**** a** R***** S****** U********* o* T******** Former A******** P******** C**** a** R***** S****** U********* o* T******** Former M****** D******* C**** a** R***** S****** M******** U********* H******* Current C**** o* c**** a** r***** s****** a* m**** m****** i********** Current D******* o* g*************** s****** a* m**** m****** i**********

Hernia repairs are something that I do very frequently and I've done hundreds of them, if not thousands. I actively practice in a clinical setting. This expert is the chief of gastrointestinal surgery, as well as the chief of colon and rectal surgery at a major medical university. He has won many honors, awards, and recognitions, such as U.S. News and World Report Top Doctors. He's been published in various journals, books, and has a patented method.

Bowel Resection Procedure Causes Abdominal Compartment Syndrome

This case involves an eight-year-old female patient who presented to the ER with a two-day history of severe abdominal pain. She had a past medical history significant for developmental delay and difficulties feeding. The patient underwent surgery to place a feeding tube several months prior to presentation. The patient was examined in the ER and admitted for observation. Abdominal x-rays were ordered but the interpretation of imaging at this time was abdominal pain due to constipation and the patient was discharged shortly thereafter. No CT scan was performed. The following day the patient returned to the hospital with increasing pain and it was at this time that a pediatric emergency medicine physician ordered a CT scan. The repeat abdominal imaging studies revealed a dilated intestine with possible perforation. The patient was brought into surgery urgently and a volvulus was discovered to be the cause of the patient’s pain. According to the medical records, the patient experienced a prolonged lack of blood supply to the abdominal viscera and subsequently sustained a significant amount of bowel necrosis by the time she finally went to surgery. The patient could not be weaned off of the ventilator post-operatively and the family decided to withdraw life support shortly thereafter.

The issue is really not whether the CT would have revealed a volvulus. The CT would show the abnormality and if there was contrast included, likely show edema and/or perforation. However, the real question will be whether the CT was indicated at the first presentation to the physician. In pediatrics, we are concerned about cumulative radiation exposure to the patient. In this scenario, I suspect that with developmental delay and the surgical procedures that she underwent, the child already has had significant imaging in the past. They key will be to review the subjective presentation (symptoms, similar to before?), objective data (elevated white count, CRP etc), and clinical response. If this information reveals a clinical picture indicative of bowel pathology it may be deemed a departure from the standard of care to not have ordered more rigorous imaging.

1. Would the CT scan have revealed the volvulus immediately and would this have made a difference in the outcome of the surgery had it been performed sooner?

Location: Maryland B.S., Duke University M.D., University of Medicine and Dentistry of New Jersey Residency, Internal Medicine and Pediatrics, University of Chicago Fellowship, Hospitalist Scholars Training Program, University of Chicago Board Certification: Internal Medicine Member, Society of Hospital Medicine Member, Society of General Medicine Member, American Medical Association Member, American College of Physicians Published, 15 peer-reviewed medical publications Research, 7 clinical research projects Former D******* A******* H***** Current A******** P******** D********* o* I******* M******* m**** m****** u********* Current H********** m******* m**** m****** c******

Non-Continental

Hawaii

This board certified expert has been practicing for over a decade. She earned her M.D. at the University of Medicine and Dentistry of New Jersey and went on to complete a residency in Internal Medicine and Pediatrics at the University of Chicago. She then underwent additional training in the University of Chicago's Hospitalist fellowship program. Her work has been published in the likes of the "Journal of Hospital Medicine", the "Journal of Invasive Cardiology", and "Archives of Internal Medicine", while she has also completed numerous research projects funded by organizations such as the American Cancer Society and the American Lung Association. Currently, this expert is an Assistant Professor in the Department of Internal Medicine at a major medical university, as well as an attending Hospitalist at multiple major hospitals.

Child Dies From Bowel Necrosis After Failure to Diagnose Volvulus

This case involves a woman who died while riding the subway system in a major American city. The subway had been stopped inside of a tunnel due to mechanical issues further down the line. Unbeknownst to the riders, the tunnel contained a large amount of carbon monoxide, which continued to accumulate as the train sat stationary in the tunnel. After several minutes had passed, a number of riders began to fall ill, reporting feelings of lightheadedness and confusion. One of the riders subsequently died from carbon monoxide poisoning. It was alleged that the ventilation system in the subway tunnel was inadequately designed to remove harmful gasses from the subway tunnels.

I can explain how the emergency ventilation system for a subway is intended to operate in the case of smoke and fire events, as well as with the accumulation of harmful gasses generally. I have worked on several including a case where a woman who died from carbon monoxide poisoning, and several cases where animals died due to ventilation failure and failure of emergency ventilation systems. I thoroughly understand ventilated air systems, tunnel ventilation fans, indoor air distribution, and the clearance of pollutants from confined spaces using ventilation air exchange. I have advised graduate students on CFD modeling of large interior air spaces. Furthermore, I serve on a committee who writes and approves emergency ventilation standards.

1. Do you have experience designing, manufacturing, or inspecting ventilation systems for subway cars or other mass transportation systems? 2. Can you explain how these systems are intended to function in events similar to the one described above? 3. Do you believe the woman's death may have been preventable had the ventilation system been designed and/or operated differently?

Carbon Monoxide Accumulation in Subway Car Kills Rider

This case involves a man who was admitted to a hospital in Nebraska for treatment of severe pneumonia and was put on a ventilator. Initially, he responded well to treatment, and was plans were made for him to be discharged. However, hours before he was due to be discharged, he developed a sudden drop in his oxygen saturation. A nurse responded and suctioned the patient, and a respiratory therapist was called to assess and manage the airway. While managing the airway it is alleged that the respiratory therapist failed to monitor the patient’s vital signs, and his heart rate dropped and he went into respiratory arrest. Despite being successfully resuscitated he sustained brain damage from oxygen starvation.

I have been an educator since 1994, and have taught respiratory care for 11 years, and managed my hospital's respiratory care area as an Associate Director of the Respiratory Care Department at a major university hospital for 8 years. Patients on mechanical ventilation should be on electronic monitoring of oxygen saturation, respiratory and heart rate, and temperature and blood pressure. Respiratory therapists must also be involved in routine ventilator checks, which would include: review of all monitored patient parameters (vital signs, oxygen saturation); patient assessment (listening to lung and heart sounds, chest movement, secretions, color); a complete check of all ventilator settings, alarms, and ventilator monitored parameters; plus any humidification or medication therapy. Many of the cases involved patient monitoring issues stemming from setup and monitoring of a transport ventilator, weaning from mechanical ventilation, failure to notice signs of respiratory failure.

1. How often do you treat patients like the one described? 2. What type of monitoring is required when assessing and managing a patient's airway?

Location: New York B.A., Queens College Therapist Diploma, New York University M.S., State University of New York - Stony Brook Board Certified, National Board for Respiratory Care Member, American Association for Respiratory Care Member, New York State Society for Respiratory Care Member, Lambda Beta National Respiratory Care Honor Society Member, Alpha Eta National Allied Health Honor Society Current C**** D******* o* D********* a** T********** S******* m**** u********* Current D******* R********** C*** P****** m**** u********* Current C******* A******** P******** m**** u*********

Midwest

Nebraska

This board certified expert has been practicing respiratory care for over 35 years. A Clinical Assistant Professor at a major university, he is also the Chair of the Division of Diagnostic and Therapeutic Sciences as well as the Director of the Respiratory Care program at the same institution. He is a member of multiple respiratory care professional organizations, including the Lambda Beta National Respiratory Care Honor Society, and has a Masters of Science in Health Care Policy and Management.

Man Suffers Brain Damage Due to Oxygen Starvation While on Ventilator

This case involves a 45-year-old female patient with a history of alcohol abuse who presented to the hospital with complaints of abdominal pain. She was admitted for management of alcohol withdrawal. During the course of her admission, the patient was admitted to the ICU. The patient eventually deteriorated and was found unresponsive with respiratory depression, however, she was taken off breathing assistance. A subsequent chest X-ray showed fluid in her lungs. Two days later, the patient suffered cardiopulmonary arrest.

I frequently manage patients with alcohol withdrawal in the ICU, many of whom have required some form of respiratory assistance (both noninvasive and invasive mechanical ventilation). Due to the medical strategies needed to appropriately manage withdrawal symptoms, patients with alcohol withdrawal require particular precautions. These include close monitoring of their ability to maintain airway latency and protection in the context of both alcohol withdrawal itself and side effects of alcohol withdrawal medications. Ideally, patients are managed in a way that avoids the need for invasive mechanical ventilation, though depending on the severity of withdrawal, this strategy may not be feasible. Typically, the ability to maintain adequate ventilation and oxygenation with an appropriate mental status and the ability to protect their airway qualifies a person to be removed from respiratory assistance in the ICU. However, specific considerations that apply to noninvasive ventilation that differ from invasive mechanical ventilation. Certain circumstances make noninvasive ventilation inappropriate even if they continue to require respiratory assistance.

1. How often do you manage patients with alcohol withdrawal that are put on respiratory assistance in the ICU? 2. Would managing a patient with alcohol withdrawal in the ICU require precautions that are otherwise not required for other patients? 3. What qualifies a patient to be taken off respiratory assistance while in the ICU?

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Ventilator Expert Witness Case Studies

Untimely Diagnosis of a Bowel Obstruction and Delay in Surgical Intervention Leads to 5-Year-Old Child’s Death

Bowel Resection Procedure Causes Abdominal Compartment Syndrome

Child Dies From Bowel Necrosis After Failure to Diagnose Volvulus

Carbon Monoxide Accumulation in Subway Car Kills Rider

Man Suffers Brain Damage Due to Oxygen Starvation While on Ventilator

Alcohol Withdrawal Patient Is Taken Off ICU Ventilator Prematurely

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