The GOOD – Short and Medium Term

The NOT So GOOD – the Long Term – we need to look at this to assess damages….

I recently worked on a case where a 20 year old male had multiple severe internal injuries from automobile inflicted trauma. One of these injuries was an aortic pseudoaneurysm. A pseudoaneurysm is a collection of blood between layers of the aortic wall and this is caused by a tear in the internal aortic wall – the tear is caused by forces of impact during the crash. The blood in the aorta pushes through the tear and fills the newly formed space created by the separation of the layers in the aortic wall. The client had a TEVAR (Thoracic Endovascular Aortic Repair) repair with resolution of this problem. Good story so far – however, the future is not so great for this young male – with an injury to a kidney and a family history of hypertension. So, what do we do with this? The kidney injury and predilection for hypertension sets him up for much earlier onset of hypertension accompanied by ASCVD (Atherosclerotic cardiovascular disease) and its consequences (heart attacks and strokes). The TEVAR repair superimposes another set of risks more rapid progression of hypertension and ASCVD. I will introduce the issue with a discussion of Aortic compliance. The aortic compliance gets irreversibly altered by the inserted [TEVAR] stent.

Arterial walls have an elastic component that allows them to stretch. This is important for the aorta as the aorta receives the entire stroke volume (about 120 ml or 4 ounces) of the Left Ventricle with each heartbeat. If the aorta was a rigid pipe, the left ventricle would have to pump this volume directly into the aorta and into the distribution arteries – this would make for a lot of work. Aortic compliance [elasticity], allows the aorta to expand as the Left Ventricle pumps each stroke volume into it and thus reduces the work that the left ventricle has to do. The aorta then recoils to its normal size and pushes the blood into the distribution arteries throughout the body. This cycle is repeated with each heartbeat and changes the pulsatile flow of blood to a steadier flow.

As people get older, the aorta (and other arteries) loose some of their elasticity. This makes the heart work harder to pump blood through the arteries. In some instances, calcium builds up inside the wall of the aorta and this causes it to get stiffer. When the left ventricle has to work harder to pump the blood into a rigid aorta, this leads to the left ventricle muscle becoming larger (Left ventricular Hypertrophy).  Additionally, the systolic blood pressure rises as the compliance of the aorta decreases. Unfortunately, medications cannot reverse the stiffness of the aorta and this type of systolic hypertension is very difficult to control. We sometimes see this picture in older folks with a stiff aorta. Even with medication, their systolic blood pressure may range above 180 mmHg. This leads to faster onset of ASCVD for that individual.

One way to understand this concept is by imagining a little play car with a piece of straw mounted on it to which you attach a balloon filled with air. The balloon recoils and pushes the air out of the straw propelling the car forward. The steady flow of air keeps the car going. Imagine now that you had a long tube attached to the straw instead of the balloon. Each time you blow out your breath, the car moves a little. You are going to get tired pretty quickly. It is much more efficient to blow up the balloon and let the recoil do the work.

I am talking about the elasticity of the aorta because it is a normal component of our circulatory physiology. When it is altered, things don’t work so well. This is directly applicable to the case I referenced above. (The aortic wall had a tear and blood accumulated around the tear but the mediastinal contents were able to limit the loss of blood – thus the client did not exsanguinate). The client had multiple injuries which took precedence and once they were stabilized, the pseudoaneurysm needed to be addressed. Generally, there are two methods of repair – 1.) open resection of the torn aorta and replacement of that section with a graft of some type. This is major surgery and has a long recovery period. 2.) Insertion of a “sleeve” along the inside of the aorta to put a patch over the torn part and seal it. This is a TEVAR procedure. Essentially a compressed stent is placed around a deflated balloon and inserted into the artery in the groin. Under X Ray imaging, the stent is placed along the aorta so that it covers the area of the aorta which has the tear. The balloon is then inflated and the stent expanded to sit right onto the inside of the aortic wall. The stent is long enough to stabilize the aorta before and after the tear. The stent then becomes part of the aortic wall and the pseudoaneurysm is stabilized and aorta now has integrity. There is a quick recovery from a TEVAR insertion procedure. The patient has yearly follow up and they generally do well. All is good and well until we look into the future and consider the altered physiology of the aorta – and cardiovascular system. This is where aortic compliance comes in.  If we consider the descending aorta to be about 30 cm in length and we place a 10 cm rigid stent in it, what do we do to aortic compliance?

The classic definition of compliance is the change in blood volume relative to a given change in distending pressure. For the aorta, the distension is a change in diameter – i.e. the aorta expands in a radial fashion as blood is pumped into it. The central Aorta contributes most of the compliance of the arterial tree since it is the largest. Now we consider the length of the central aorta to be 30 cm and we have just introduced a TEVAR device which is 10 cm in length into the central Aorta. The TEVAR device has minimal elastic properties (It is essentially a wire metal cage covered with special material) and it becomes part of the aortic wall. Thus, 10 cm of the aorta has lost most of it’s compliance because it can no longer expand to fill with each heartbeat – the diameter here is largely fixed. In essence, we have accelerated the effective stiffness of the aorta to that of a 70 – 80 year old. And yet, the client is still a 21 year old. So now we have a 21 year old male with cardiovascular dynamics of a 80 year old person.  His heart is normal but it will work extra hard, all the time, because of the loss of aortic compliance.  The net effect will be earlier onset of ASCVD related issues. It is very difficult to control the high blood pressure because we cannot alter the compliance of the aorta. This will lead to earlier onset of strokes, heart attacks and worse – systolic heart failure. Additionally, the same high blood pressure will adversely affect the kidneys leading to earlier kidney failure. Considering all of these things, we are predicting that this once very healthy and athletic 21 year old male will probably get into kidney failure in 20 – 25 years.  He will be about 45 years old. He will most likely need kidney transplant at that time. Additionally, the constant increased workload on his heart, coupled with high blood pressure will lead to heart failure – probably in 25-35 years. Again, he will be about 50-55 years old and may require a heart transplant at that time. Modern technology is marvelous. We are able to do things which were not possible 10-15 years ago and we are able to rescue more people after serious injuries. However, if we do not look at the long term consequences of these interventions, we fail to fully assess damages in legal cases.

The Medical Evaluation Board (MEB) and IDES ( Integrated Disability Evaluation Services)

As I was approaching the end of my career, I had decided that I would like to be of service to my country – so, I signed on to serve on the Medical Evaluation Board of the US Army at Ft. Hood. I quickly realized that I had a lot to learn about the military and its operation.  I had to learn about  Military Services Standards of Medical Fitness  contained in  the Army Regulations AR 40-501.  In essence, this is a list of diseases, deformities or malfunctions of the body and how bad they can be with regards to medical fitness to serve in the military.  These standards are used to evaluate prospective candidates who have a medical issue to see if they can join the military.  These same standards are employed when soldiers get sick or injured.  The Army allows one year of treatment for a medical problem and if it has not been resolved, the case is evaluated by the MEB (Medical Evaluation Board) to decide whether the military member is still fit to remain in service or whether they need more care or they should be medically separated from military service.  The MEB is a group of physicians who gather all the information for a case and discuss it and make recommendations for retention in the military or medical separation – these recommendations are forwarded to the PEB ( Physical Evaluation Board).  The PEB is the group which makes the final determination on retention or separation of the individual from the military.

Joining the Army is much like making a career choice.  After taking an aptitude test, potential recruits are assigned a MOS ( Military Occupational Specialty). They sign a contract that they will do their MOS training and provide MOS services as well as basic Army services to the US Government. The US Government signs a contract with the person that they will provide MOS and Army training and will provide training for advancement and careers within the Army. Thus, it is a two-way binding contract.  There are many ways that this contract can be broken but the focus of this article  is on medical standards of fitness for soldiers to remain in the Army.

Injured military personnel receive treatment through their primary care team and are referred  for specialty evaluation/care.  If surgical procedures are required, they are completed.  The goal is to fully restore the injured person to enable them to continue their military career.  The Army allows for one year of care to get the soldier back to normal and back to duty.  If the illness is severe or the repair of any injuries with rehabilitation will not allow them to continue their military duties, then they are referred to the MEB where it is determined whether the soldier has received all the necessary care and whether they might not be able to return to duty.  If the soldier has not received all necessary care and interventions, they are referred back to their primary care team with recommendations.  However, if all possible care has been rendered and the soldier is not able to return to duty, the MEB evaluates them according to the Military Services Standards of Medical Fitness.  If they do not meet fitness standards,  the MEB recommends to the PEB that the soldier be medically separated from the Army.  The PEB has the power to medically separate the solder from the Army or to assign them to a new MOS within the limitations given to them by the MEB.

The focus of the MEB is to serve 3 goals:  1. Protect the soldier; 2. Protect the other soldiers; 3. Protect the interests of the United States Government.

1. Protect the soldier. In some cases of injury or illness, the soldier’s medical or mental health is compromised to the point that continued Army service could be detrimental to their health. They might have difficulty performing some aspect of their MOS or performing basic soldier duties. As an example, an injured soldier may be returned to normal function but may require some special medicines to treat their medical problem. In the case of highly specialized medicines, these might not be available if the soldier is deployed to remote areas.  This has to be considered as the Army goal is to have every soldier immediately deployable to any location at any time.  Should this soldier be deployed and not be able to obtain their needed medication, their medical problem may be significantly aggravated.  Thus, they may be at significant  risk if deployed.
2. Protect other soldiers. We are concerned with protecting everyone. If an injured solder is not able to perform their MOS to their fullest capacity, we do not want other soldiers to be at risk.  For example if a radio technician soldier can’t climb a pole to install an antenna so that the group can radio their location and request needed assistance, the entire group might be at risk.  Thus, it is the MEB’s job to make sure that ill or injured soldiers are accurately evaluated and treated and proper restrictions placed on their activity with Profiles.
3. Protect the interest of the federal government. Since the federal government is the ultimate employer, we must be aware that we not put the federal government at risk by any MEB decisions about soldier suitability for their MOS or soldier responsibilities. Let me give an example.  Lets take an Army cook who is attached to a unit getting ready to deploy for a combat mission.  The cook has a walking boot on their foot for a fracture of the 5th metatarsal bone which is healing very slowly – maybe over 12 months.  The commander’s argument for the soldier to deploy with their unit goes like this: “Joe, our cook, is in the kitchen all the time and does not go outside “the wire” and thus is able to do his duties within the confines of the camp and we need the cook to be deployed on our mission.”  This is a safe argument for the commander  –  until the camp is attacked and they have to quickly mobilize.  Since Joe can’t run, several soldiers have to assist and maybe carry him – they can’t leave him.  This slows down the group and maybe Joe and several other solders get injured or killed.  Looking at the big picture, one asks the question “Why did they let Joe get deployed when he clearly could not run with a leg boot and a foot fracture that has not healed – and several soldiers were injured or killed because of it?”  This is the correct question. It is questions like this which the MEB has to ask and intervene for the soldier so that they are not deployed with a serious ongoing medical problem.  In this scenario, the federal government may be at risk for the decision to deploy Joe and for the injuries and loss of life subsequent to the attack on the camp.

When the MEB finds that the soldier does not meet retention standards after treatment has been rendered, then the solder goes through the IDES process. The MEB report is one component of the IDES process.  The soldier’s packet is then forwarded to the PEB. The PEB makes the final determination on separation or retention.   The IDES process integrates the DoD Disability Process and the VA Disability process. This makes sure that the individual’s medical issues are clearly identified and that they will receive continued care through the VA health care system.

OSA (Obstructive Sleep Apnea)  –  IT IS AS BAD AS IT SOUNDS!

I recently consulted on a case where OSA was center stage in a motor vehicle accident. Although the defendant had multiple significant medical issues, the lack of proper CPAP use (including lack of documentation of proper use), and little documentation of appropriate medical management of their OSA led to a finding of causation in the accident – in essence, the driver was not using their CPAP and fell asleep at the wheel and caused a major accident.  This led me to bring up several thoughts about OSA which I will share.  Over the years I have encountered many patients with OSA who simply stop using their CPAP or fail to use it consistently or fail to make sure that it is at the correct setting by not doing appropriate follow up testing.  This is not good!  Nightly use of effective CPAP is necessary unless there is some other appropriate OSA intervention.  These other interventions might be a large weight loss or use of a mouth prosthetic or throat surgery (UPP uvulopalatoplasty surgery) for OSA.  

30 years ago, when OSA was relatively unknown, our methods and tools were quite basic.  We would find folks who would say “doc, I was driving down the road and next thing I knew I woke up after hitting a tree”.  That would start the OSA workup – and there were very few Sleep Labs at that time.

Our screening questions were also quite basic and went like this:  1. Do you fall asleep when you don’t want to or expect to?  2. Do you fall asleep when you watch TV?  3. Do you nod off at stop lights?  4. Are you tired all day?  5.  Do you wake up with a full day’s energy or do you wake up just as tired as when you went to bed?  

Another set of questions went like this:  1. Do you make loud “snoring” noises at night?  Actually, the “snoring” is NOT the nice sonorous “sawing wood” or  ”zzzzzzz’s” – it is choking and sputtering and gagging noises.  2.  Have others banished you to a distant sleeping location (couch or basement) because of the noises you make when you sleep?  3. Have others complained about the noises you make at night when you are sleeping?   Often the spouse would be questioned.  Responses are often: “I have to wear ear plugs at night to be able to sleep because he snores so badly” or “I don’t get any sleep because he stops breathing and I have to poke him in the ribs or roll him over to get him to start breathing again.”

Times have changed!  With the internet, anyone can go online and find an OSA screening questionnaire that they can take.  They can record their own sleep with a smart watch or smart phone and identify episodes of OSA.  Some of the preliminary tests for OSA can be done at home to help make a diagnosis.  However, the “Sleep Study” – (polysomnography) – is the gold standard.  Frequently, patients will have a “split” sleep study – the first half of the night, they are monitored for OSA and if there is overwhelming evidence of OSA, then the second half of the night is used to titrate CPAP to eliminate the OSA.

30 years ago, CPAP machines were essentially the back end of a vacuum cleaner with some pressure regulation.  They were loud and bulky.  Patients often put them in a closet or adjacent room and drilled holes in the wall for the hoses.  Masks were limited to one or two designs and were quite stiff.  Patients always complained about them but said “I use the mask and CPAP because I feel so much better in the morning – I feel normal when I use it!”.  Today’s CPAP machines are small and quiet.  Some are portable and battery operated.  There is a large variety of masks – full face, mouth, nasal pillows and combinations.  Patients are encouraged to keep working with the respiratory therapist until they get the mask that fits and works the best.  The air delivered to the CPAP mask can be heated or cooled and can be humidified or dehumidified.   Some CPAP devices can Auto Titrate the pressure of air delivered to eliminate sleep apnea. Almost all CPAP devices have technology to monitor sleep, use. apnea episodes and CPAP effectiveness. Many can transmit this information to the medical provider.  This feature is most important especially for commercial drivers. Additionally, some insurance companies will not pay for the monthly rental of a CPAP machine if the patient is not transmitting information about nightly use and effectiveness.

OSA BEHIND THE SCENES- THIS IS THE BAD PART:

What is OSA?   OSA happens when the upper airway gets blocked – usually by the tongue relaxing and flopping backwards and closing the airway when sleeping- blocking inhalation – essentially causing a choking episode.  Sometimes the upper airway itself is very compliant and under the negative pressure used to take in a breath, the upper airway collapses and closes.  Either of these mechanisms can lead to a choking event – the upper airway blocks and the chest may be working to pull in another breath but the blocked airway does not allow this. (This causes the choking and grunting sounds of OSA patients.) The choking leads to loss of oxygen in the blood (desaturation) and to the release of adrenaline – as it would be when one is being choked by any method. The adrenalin release is part of the “fight or flight” response to danger.  The problem is that adrenaline raises the Blood Pressure and heart rate and this constant release of adrenaline causes premature ASCVD (arteriosclerotic cardiovascular disease) with its attendant consequences of High Blood Pressure, Heart Attacks and Strokes. The bottom line is that folks with uncontrolled OSA beat up their cardiovascular system every night – and increase their risk for early onset Cardiovascular diseases.  Eventually, a cough or exhalation leads to pushing the air up out of the lungs and pushing the obstruction out of the way.  This is followed by rapid breathing to make up for the oxygen deficiency.  This rapid breathing may occur in the setting of a partial airway obstruction leading to the loud and irregular sputtering and gagging noises characteristic of OSA.  The patient often does not wake up with these events and are unaware of the events.

Many patients with OSA really don’t think much of it and say “Doc, I am sleeping – I don’t care. I just am tired all the time.”  There are 5 stages of sleep.  Most people are aware of being awake or asleep.  However, the goal of sleep is to get about 2 hours of REM (Rapid eye movement -typically Stage 4 sleep) sleep each night – THIS IS WHEN WE RECHARGE OUR BATTERY for the next day!  We get bursts of REM sleep – 20 minutes here, 30 minutes there and 15 minutes, etc.  These episodes add up.  The problem is that as a person goes into deep sleep and REM sleep, the muscles relax more and more.  This can allow the tongue to flop back into the throat and obstruct the airway or allow the upper airway itself to narrow.  So, as a person gets closer to the needed deep sleep and REM sleep, they tend to have more OSA episodes.   They do not necessarily wake up but they bounce between Stage 1 and Stage 3 sleep – getting very little of the necessary REM sleep that they need.   The bottom line is that the patient with significant OSA becomes VERY SLEEP DEPRIVED – because they do not get enough REM sleep – not enough to “recharge their battery every night”.  This leads to overwhelming tiredness during the daytime and nodding off or falling asleep during the daytime when one does not want to or expect to.  This can happen while sitting quietly or even while driving a car or truck or running equipment.   

What is CPAP?  Continuous Positive Airway Pressure ( CPAP ) is the most common method we use to prevent the upper airway blockage.  CPAP pressure is measured in centimeters of water.  This is a constant flow of air from the CPAP machine sent through the mask into the airway to maintain a specified pressure to keep the tongue from flopping back into the airway and to keep the upper airway from collapsing.  Today’s CPAP machines have lots of technology to measure use and effectiveness and some will change settings automatically so that OSA episodes are eliminated.  Some machines relay this information to your Pulmonary medical provider through Apps, the internet or by means of a smart card which you can take to your provider.

OSA BOTTOM LINE:

CPAP utilization and effectiveness and regular visits with your OSA physician manager are essential to maintain good health and may be the key to continuing to maintain your Medical Certification and CDL. 

Use of CPAP and documentation of CPAP effectiveness by electronic transmission or by means of a memory card to your OSA physician manager provide the proof that you are working to effectively manage your OSA and maintain safe driving.

Information on Obstructive Sleep Apnea and Commercial Driving:

The following is a link to a report from the   University of Pennsylvania and sponsored by the Federal Motor Carrier Safety Administration (FMCSA) and the American Transportation Research Institute of the American Trucking Associations found that almost one-third (28 percent) of commercial truck drivers have mild to severe sleep apnea.   https://www.fmcsa.dot.gov/sites/fmcsa.dot.gov/files/docs/Driving-Sleep-Apnea_508CLN.pdf

Another good resource is Trucker Docs: https://dotphysicaldoctor.com/commercial-drivers-manage-sleep-apnea-maintain-cdl/   

Trucker Docs has lots of good information about OSA and CDL license and the role of the driver and the carrier for treatment and safe driving.

A Common Problem after Unexpected Trauma

Doing Medical/Legal Consulting is a great way to use your medical training in a non-clinical field that really helps people. Here is another way you can help the attorney, the case and the injured client by identifying an undiagnosed injury in the case.

Depression is one of the most common sequelae of unexpected trauma and often missed as a diagnosis after multiple trauma. Understandably, patients and doctors are focused on the acute physical injuries after an accident. Often times, the patient’s depression following physical trauma is missed.

Depression is characterized depressed mood, sleep disturbance, appetite disturbance, loss of libido, intrusive thoughts, crying spells, difficulty concentrating & decreased attention span. In addition, depression is characterized by feelings of helplessness, feelings of hopelessness, anhedonia (inability to experience pleasure), low self-esteem, loss of interest in social activities & relationships, feeling overwhelmed, fatigue, irritability and occasionally suicidal ideation.

If it is your opinion depression is a medical damage in the case and a medical condition that needs follow up diagnosis and treatment it is your job to both discuss this issue with your attorney client and to make sure this ongoing medical problem is in your report.

The above is used with permission granted by Dr. Armin Feldman

And now for the rest of the story:

Many years ago my family and I were moving from one job to another in a different state.  I took 4 weeks off from my medical practice to move and help my wife with 5 little children.  The move went well – in the middle of a snow storm – from Maine to Massachusetts.  Getting the new house went well once the boxes were unpacked – 4 days.  Then it was getting used to our new quarters and area.  We had friends and family in our new area and that made it easier.  About the 3rd week into my time off, I started getting depressed.  I had to do some self inventory and realized that I was getting depressed ( I don’t get depressed) because I was not going to work and earning money for my family!  I left a good job and had another good job ready to go.  Once I realized this, I was able to deal with it and enjoy the rest of the time with my family.

I then realized that if I had some mild depression just because I was not working – and I had a stable and secure future – how hard is it for injured or sick patients who get depressed and do NOT have a secure and stable future ahead of them.  They may be looking at extended time without work or even never being able to work again in their chosen field.  The outcome may not be known for most patients.  This is hard for them to deal with.

The result was that I was pro-active in addressing depression with my sick and injured patients right up front.  Even educating them so that they could seek help if they found the warning signs of depression creeping in.  In my practice, I have found that helping patients manage their depression, compassionate kindness, wise counsel and encouragement had a great reward in helping them manage their illness, injuries, rehab and the rest of their life!

Early on in my medical career I had top notch consultants available to help me even though I was in a rural area in Maine.  I remember my lawyer advising me – “don’t ever forget to write your notes and put in some indication of what you are thinking”.  Interesting statement, but after some discussion, my lawyer told me “if there is nothing in the record – I have nothing to work with – if there is something to indicate what you are thinking – then we have a position to go from.  You don’t have to write everything but make sure there is something to indicate your thoughts.”  Over the years I have learned to include information in my records about my thoughts so that they can be clear to my lawyer, the jury and the judge. This is also helpful when others are providing care for the same patient.  That is just how I learned to function in my practice and it has worked very well. Fortunately, I have not needed to test this in court.

This was easy when I started my career and medical notes were hand written, typed or dictated.  The thoughts expressed were coherent and flowed.  The advent of EMRs  brought about the era of many mouse clicks with bits of information which may not be connected very well or at all.  Some providers get paid by the mouse click!  Additionally, “copy forward” has its own set of issues – including erroneous information being copied forward!  I used to review copious EMR records from Boston Hospitals that often ranged hundreds of pages.  Once I learned the “templates” it became easier as the real information and thought processes entered by the provider might be contained in only  1 or 2 sentences.   I just had to find them!

Reviewing medical records today is more difficult due to EMR issues.  Additionally, the flow of care may not be stated outright but may be abstracted from the information contained across several EMR notes.  Some information may not appear relevant but within the context of the review, it may be highly important.  These are some of the reasons that seasoned providers should do medical record reviews in any complicated cases.

If you have clients and need medical information and / or direction, consider involving a seasoned physician to review the records so that you can get up to speed quickly and your client can have ALL their issues addressed!

This is a sample of a Medical Summary Report that we would do for your client at your request.  This report may help you see the value that is created in Medical Summary Reports.  It includes a list of medical issues with history and findings and medical opinions.  It is a bit of a long read, but it will help you get a sense of the product that we can supply.

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Re: KC

Dear Attorney Doe,

You have asked me to prepare a Medical Summary Report on your client KC As you know, KC is a 49 year old woman who was involved in a rear-end auto crash on June 13,2017. This report will outline my review of the case and provide my opinions and comments concerning KC’s injuries. I reviewed the medical records you provided and then interviewed KC for one hour by telephone on 1-4-18.

Records Reviewed

Neurology Clinic, Inc.-W.J.W., M.D. 7-6-17 to 12-17-17

St. Augustine Hospital-Emergency Department 6-13-17

Methodist Hospital-Emergency Department 7-28-17

Jones Family Practice Clinic, PC-D.A.J., D.O. 6-14-17 to 12-22-17

Employer Records-Prescott County Mental Health Network 8-21-17 to 10-15-17

Wood Fire Department-Pre-Hospital Care Report 6-13-17

The Smith-Orange Clinic-A.J.C. M.D. 7-11-17 to 12-2-17

Physical Therapy Associates-M. C., PA-C 6-25-17 to 8-13-17

Tooth & Associates Dentistry-M. B., DDS 5-15-17 to 12-20-17

Apple Physical Therapy, P.C.-A. F., PT, DPT, COMT 11-11-17 to 12 28-17

Southern Hospital 10-11-17

Northeast Massage Therapy Associates 7-16-17 to 9-9-17

Brief History of Events

On June 13, 2017 KC was the properly restrained driver of her vehicle. While stopped at a traffic light her car was rear-ended by another vehicle. KC reports the offending vehicle was traveling at a high rate of speed. She further reports her car was pushed forward “5-10 feet” by the offending vehicle. The accident report from the Colorado State Patrol verifies the distance KC’s car was pushed forward.

Immediately after the crash KC noticed the immediate onset of neck and low back pain. She was taken to St Augustine Hospital Emergency Department. X-rays did not show any fractures, dislocations or other acute problems although a subsequent MRI did show a ruptured disc at C4¬C5. KC’s neck and low back pain has persisted since the auto crash.

Approximately one day after the accident KC began to experience severe neck pain.

KC reports her neck pain initially to be a 7/10 on a pain rating scale. The pain rating scale is based on zero representing no pain and 10 representing pain severe enough to lose consciousness.

KC also reports having low back pain immediately after the accident. She reports her low back pain as 2-3/10 on a pain rating scale.

KC reports immediate moderate pain in her right temporomandibular joint (TMJ). She reports the pain as 4-5/10 on a pain rating scale.

KC states she has been in medical treatment since the accident.  She has seen many specialists and has had several different proposed diagnoses regarding her neck. In reviewing KC’s records, it appears that she has been diagnosed by various treating physicians with differing opinions as to her cervical diagnosis. I could not find in the record that there has ever been a consensus as to her cervical diagnosis. In fact, there have been differing interpretations with regard to reading her cervical MRI’s. The general consensus, however, is that the cervical MRI’s show cervical disc herniation with bilateral nerve root impingement and compression at C4-C5.

In addition to KC’s physical maladies she also reports experiencing depression which has required a multi-drug approach for treatment. KC reports the onset of depression approximately one week after the accident. It should be noted KC denies any previous problems with depression or any past psychiatric problems.

What is certain is that KC has several ongoing problems that are a direct result of the June 13, 2017 auto crash. She is unable to work due to auto crash injuries. These problems are detailed below.

Medical Record Review-Pertinent Verbatim Notes

D.J. , MD

7-31-17

This 49 year old right handed woman was struck from behind by an SUV on June 13th, 2017. She underwent MRI showing a small disc herniation at C4-5 with mild impingement.

Impression: Posttraumatic cervical radiculitis which has been predominantly left sided with some mild right sided involvement. Headaches are most likely cervicogenic and posttraumatic.

8-18-17

Impression: Bilateral cervical radiculitis with C4-5 disc herniation-improving with conservative measures.

9-26-17

Chronic cervical radiculitis which is posttraumatic

10-23-17

Recent exacerbation of pain. TMJ untreated. Depression

10-31-17

Recent syncopal episode of uncertain etiology

9-28-17

1. E, M.D.

Depression.  The depression began in 2017. (after auto crash).

7-28-17

Methodist Emergency Department Report

She states the pain to be severe and worse with movement and not improved with home regimen which includes Ultram, Percocet, Wellbutrin, Zoloft, Soma, Lyrica and Klonopin.

6-30-17

She has left-sided neck pain and left upper extremity symptoms as well as the left lower extremity symptoms. She has more numbing and tingling sensations with overall weakness in general in her left arm. She has passed out three to four times and has had near passing out situations, since the motor vehicle collision. Possible etiologies would include an upper cervical facet injury just due to the type of symptoms that she reports.

7-11-17

(Through Dr. C’s office notes) MRI Cervical Spine without contrast Impression C4-C5 through C6-C7 mild disc degeneration.

Findings: Normal cervical lordosis is reversed.  C-4/C-5:  Central disc herniation results in mild thecal sac narrowing and bilateral nerve root compression. C-5/C-6: Disc bulge and uncovertebral degeneration result in mild thecal and left foraminal narrowing. C-6/C-7: Uncovertebral joint degeneration results in minimal left foraminal narrowing.

Assessment: I. Cervical Facet Syndrome 2. Cervical Myofascial pain syndrome.

7-14-17

Cervical Intra-articular facet injection LT1, LT2 and LT3

8-03-17

Assessment: 1. Cervical Facet Syndrome 2. Cervical Myofascial pain syndrome 3. Painful Cervical Dystonia 4. Lumbar Myofascial Pain Syndrome

9-10-17

KC is seen today for proliferant injections. She has been doing well with proliferant injections to date.

10-05-17

She also states that she has been having some increasing back and left leg pain. Assessment: Ongoing lumbar radiculopathy of the left. At this point, I think it would be appropriate to treat that with a transforaminal epidural.

10-17-17

Assessment: Cervical Enthesopathy

11-12-17

MRI of Lumbar Spine

Annual tear at L5-S1 narrowing the lateral recess and contacting the right L5 nerve root. Contact on both exiting L4 nerve roots at the L4-5 level.

11-25-17

Left occipitoantlanto facet syndrome. Ongoing lumber radiculopathy on the left. I think it would be appropriate to treat with transforaminal epidural.

9-05-17

IMS trigger dry needling. Assessment: Diffuse neuromyofascial pain syndrome.

8-15-17

1. B., DDS

Pt presents with facial pain secondary to a motor vehicle accident and temporomandibular pain during function.

Ongoing Medical Problems (in order of severity)

Neck Pain, Numbness and Tingling

KC states that her daily neck pain is her most significant ongoing medical problem since her auto crash on June 13, 2017. On a daily basis KC reports that she currently averages 4-5/10 pain on a pain rating scale. (Zero represents no pain and 10 is pain significant enough to lose consciousness.) KC’s average pain level would be higher if she did not take Percocet (pain medication) regularly. The pain starts between the base of her skull and the upper most cervical vertebrae and radiates bilaterally into her shoulders with intermittent radiation into the left arm. In addition to pain KC states she also experiences intermittent numbness and tingling in the left arm. KC reports that she has exacerbations in her pain level approximately four times per week in which the pain level raises to 7-8/10 and the only thing she can do to cope with the pain is lie down and try to remain still until the pain subsides back to her average daily level. KC reports she has not been pain free since the auto crash.

KC reports there are several things that will lead to an exacerbation of pain above her daily average. KC states that she now lives with a friend who moved in to help KC do most of her activities of daily living as these kinds of activities will exacerbate her neck pain.  KC states she can no longer cook for herself, do housework or wash her own clothes. KC also reports difficulty dressing if she needs to reach behind her neck or back. In fact, KC states that any increase in her low level of daily activity will make all of her neck symptoms significantly worse. With an exacerbation, her pain level reaches as high as 8/10.

KC also reports that the position of her head can exacerbate her pain level. If KC sits too long with her head flexed (bent forward), for example reading a book, the pain can increase to 7-8/10. She also states that if she extends (bent backwards) her neck to look upward she will experience pain at the 7-8/10 level. When the pain level is 7/10 or higher, KC reports she has no choice other than lying down until the high pain level subsides to her average 4-5/10. KC may need to lie down for several hours to reduce the pain level. KC states “My cervical pain is overwhelming.” KC reports her average pain level was higher than 4-5/10 until she had a myobloc injection done in October 2017 and repeated in December 2017. The myobloc injections were performed by Andrea Charles, M.D. at the Smith-Orange Clinic. She is scheduled for another myobloc injection in February 2018.

It should be noted KC denies ever having neck pain prior to the auto crash and medical records of her primary care doctor substantiate KC has no previous history of neck pain.

Depression

KC reports that approximately one week after the auto crash she developed depression. She characterizes the depression as depressed mood, feelings of being overwhelmed, difficulty falling and staying asleep, anxiety, hopelessness, helplessness, intrusive thoughts, decreased concentration & attention span, self-imposed social isolation and irritability. KC states: “Now I have a decreased ability to handle stress. It’s hard for me to be around people.”

It should be noted that KC was divorced approximately 9 months after the accident. KC reports she started suffering from depression shortly after the auto crash and reports being saddened by the divorce, however, she also felt relieved due to her husband being vindictive towards her after the accident.  lt is also important to note that KC’s depression started before her decision to get divorced. There was no change in her depressive symptoms after KC and her now ex-husband separated and subsequently divorced.

KC states she is plagued by intrusive thoughts. She reports repeating the accident over and over in her mind, however, she complains that the worst of her intrusive thoughts have to do with feeling “I have no control over my body.” She also states “My life has been turned upside down and my body died.” KC is very worried about the future and what will become of her because she does not see an end in sight regarding her neck problems. She is measured and rational about her future pain level stating that she does not think her pain will completely resolve. She hopes her treating doctors can get her pain level down to a more manageable level that is not completely incapacitating as it is now. KC feels reducing her average pain level will help to resolve her depression. KC is currently discussing possible spine surgery with her doctors.

Low Back Pain

KC reports the onset of low back pain starting at the same time as her neck pain, that is, shortly after the auto crash, however, KC’s low back pain was mostly disregarded by KC and her doctors due to her overwhelming neck pain. As described, the low had pain is currently intermittent. The pain starts in the L5-51 region with radiation to her sacrum, right buttocks area, and down through her right hamstring area KC reports on a pain rating scale the average pain is in the 4-6/10 range when it does “flair up.”

KC reports increased activity will cause her low back pain to increase. She specifically reports she gets increased pain with moderate walking or sitting and with other unavoidable activities of daily living. As noted above in the July 6, 2017 note from Dr. C, a lumbar MRI shows an annular tear at L5-51 with narrowing of the lateral recess and that the herniation is contacting the right L5 nerve root as well as contacting both exiting L4 nerve roots in the 14-L5 level. KC reports she fell approximately four months after the auto crash confounding the etiology of her low back pain, however, it is clear the low back pain started after the auto crash and before her fall. KC reports she received one epidural steroid injection at the L4-L5 level which helped reduce her level of low back pain. KC has no previous low back pain history prior to the auto crash.

Temporomandibular Joint Pain (TMJ)

KC was diagnosed by Milton Belle, D.D.S. in 2017 after the auto crash as having bilateral TMJ dislocations.  KC reports she is experiencing ongoing problems from the TMJ dislocations secondary to the auto crash. She reports “my jaw is disconnected and it doesn’t hang right.” KC reports having bilateral jaw pain which is made significantly worse with chewing. She has had to give up foods that are too hard for her to chew. Currently her jaw pain is intermittent and the pain level in her jaws rates 2-4/10 when the pain occurs. KC also reports the TMJ problems have caused difficulty in the pronunciation of common words. KC did not have jaw pain prior to the accident and has no previous history of jaw dislocations.

Discussion

All of my opinions arc made to a reasonable degree of medical probability.

Neck Pain

There are several mechanisms of action accounting for KC’s ongoing neck pain. She has been diagnosed with a cervical Myofascial Pain Syndrome. In addition, she had been diagnosed with a bilateral C4-C5 disc herniation as well as Cervical Dystonia. I would opine that KC has more than one cervical diagnosis as a result of the rear-end crash. There is no question KC has a cervical disc herniation as confirmed on a cervical MRI done shortly after the auto crash.

Unfortunately, steroid injections did not help her cervical pain which can be the case with some patients with disc herniation. In addition, it is my opinion that KC also has cervical pain from a soft tissue injury to the cervical region best diagnosed as a severe Myofascial Pain Syndrome.

This term refers to inflammation in the body’s soft tissues. Myofascial Pain Syndrome may involve either a single muscle or a muscle group. In KC’s case the soft tissue throughout the left side of her neck is affected.  In some cases, the area where a person experiences the pain may not be where the myofascial pain generator is located. Experts believe that the actual site of the injury or the strain prompts the development of trigger points that, in turn, cause pain in other areas.

KC has pain throughout the left side of her neck. KC’s myofascial pain developed from the muscle injuries to her cervical muscles and injuries to the cervical ligaments and tendons. It is also my opinion that KC has involuntary contractions of the neck muscles as well, causing an awkward posture of the head and neck associated with muscle spasms. With whiplash injuries caused by rear-end collisions it is not usual to have multiple injuries causing pain.

One of the most critical factors in KC’s neck pain is the C4-C5 disc herniation. There is a seminal 2014 American Journal of Neuroradiology paper addressing the nomenclature of disc herniation. The findings apply to not only to lumbar herniation, but cervical herniation as well. The journal article states “When data are sufficient to make the distinction, a herniated disc may be more specifically characterized as ‘protruded’ or ‘extruded’. These distinctions are based upon the shape of the displaced material- They do not imply knowledge of the mechanism by which the changes occurred and, thereby differ from definitions that base distinction upon whether and how disc material has passed through a defect in the annulus.” The paper also states “The term herniated disc as defined in this work, refers to localized displacement of nucleus, cartilage, fragmented apophyseal bone, or fragmented annular tissue beyond the intervertebral disc space (disc space, interspace).” The radiologist in his report is clearly stating that at the C4¬C5 cervical level KC has a disc herniation by the definitions accepted by the American Journal of Neuroradiology paper. Due to the herniation KC is getting mechanical nerve root impingement which clearly causes pain.

There have been hundreds of papers written and it is widely accepted that disc herniation causes a chemically mediated inflammatory reaction which causes pain just as severe and intense as when the herniation actually impinges on the canal or nerve root (which it does in this case). How this kind of disc pathology can cause chronic pain is outlined in the papers I have enclosed including the 2016 review article in Pain Physician, Internal Disc Disruption and Low Back Pain by Sehgal and Fortin. The principle outlined in the Sehgal & Fortin paper also applies to the cervical discs. The article states that “loss of normal distinction between the nucleus pulposus and the annulus fibrosus, gross disorganization and fissuring of the annulus, preserved external disc contour and appearance, and absence of nerve-root compression” can still cause significant pain. The paper goes on to state “Chemical sensitization of nerve endings occurs with release of nociceptive (pain causing) substances by the disc.” The paper also states with disc herniation “Phospholipase A2 liberates arachidonic acid from cell membranes and is the limiting factor in the production of powerful inflammatory mediators, i.e., prostaglandin and leukotrienes. It has a direct neurotoxic potential in addition its potent inflammatory and edema-producing properties. Phospholipase A2 is implicated in the genesis of pain in herniated discs.”

In addition, in several papers concerning cervical whiplash injuries it is well known that one of the results of whiplash can be myofascial injury resulting in pain and cervical dystonia The three conditions causing KG’s cervical pain are, obviously, not mutually exclusive.

It is my opinion to a reasonable degree of medical probability KC will most likely require surgery (discectomy and perhaps cervical fusion) to treat her neck pain and other symptoms.

Depression

It is my opinion that KG’s current depression is a reaction to her current medical condition. When faced with doctors diagnosing concurrent medical conditions causing pain and less than expected results from treatment, it is not usual for patients to develop depression. KC’s depression is characterized by depressed mood, intrusive thoughts about her medical condition, feelings of hopelessness and helplessness with regard to her medical situation improving, distress about the loss of her previous good health and her loss of the activities of daily living and the activities that brought her great pleasure such as dancing.

KC had one brief bout of reactive depression when she realized her marriage was going to end in divorce. KC was not depressed at the time of the 2017 auto crash. The fact that she was not depressed at the time of the accident and that she had another episode of reactive depression only goes to support my opinion that KC’s current depression is also reactive, however, her current reactive depression is secondary to her current medical conditions that are a direct result of the 2017 auto crash.

It is my opinion to a reasonable degree of medical probability KC should be afforded both psychotherapy and psychiatric medication treatment

TMJ Dislocations

A common result of a rear-end collision is TMJ dislocation as reported in a 2016 article in the Journal of the American Dental Association. Dr. Belle made the TMJ diagnosis on KC’s first visit by physical examination and tomograms on September 17, 2017. Dr. Belle stated in his initial note “Clinical exam and history would support a recent process in the temporomandibular joints.” He goes on to state the TIM condition is bilateral. Dr. Belle states in his clinical assessment “The patient presents with facial pain secondary to a motor vehicle accident and temporomandibular pain during function.” Dr. Belle treated KC with both night and day splints. He did not want to add other treatments until KC’s neck problem could he better determined and treated.

KC currently reports that she has intermittent facial and Jaw pain. KC is uncertain as to what precipitates a facial and jaw exacerbation other than chewing hard food. She does have painful exacerbations not related to chewing hard food. When she has pain, KC rates the pain as 2-4/10. By making a conscious effort to move her jaw less the pain will resolve. One of the consequences of needing to rest her jaw is that this action reduces her ability to interact with others and socialize. The isolation KC experiences only adds to her depression and allows her intrusive thoughts, outlined above, to exacerbate as well. In conjunction with her isolation, she notes increased neck pain as she is tuned into her symptoms rather than interacting with others. KC did not have a TMJ problem before the accident.

It is my opinion to a reasonable degree of medical probability KC should continue her treatment with Dr. Belle for her TMJ disorder.

Summary

All four of KC’s ongoing medical problems are severe and need ongoing medical treatment. In addition, there has been a dramatic change in KC’s pre-accident normal life. She cannot work, she is often non-functional due to pain and she often sees nothing to be hopeful for in the future. It is my opinion that KC does exert maximum effort under these circumstances, however, no amount of “trying to do better” will overcome these severe medical problems.

As noted above, KC is not completely incapacitated every day allowing insurance company agents to surreptitiously video record KC doing some activities of daily living. i do not see her activity on the video as having any relevance to her case.

If it would be helpful, can prepare a supplemental report outlining future medical care and costs.

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Used with permission granted by Dr. Armin Feldman .

Defense experts commonly opine that forces encountered in low speed collisions are insufficient to cause serious injury.

PDMG Consulting response:

On the contrary, there is ample evidence in medical practice, backed by credible literature that indicates that collisions at low speeds as low as 10 km/h can do much harm to the human body.

One such example involves the cause of thoracic outlet syndrome (TOS). Medical literature notes TOS to be a combination of neck and or shoulder trauma plus an anatomic predisposition.

Neck or shoulder trauma, caused for example in auto crashes, as a causative factor of TOS resulted from observations reported by a few thousand patients whose symptoms of pain in their necks and arms, as well as numbness in their hands, developed soon after a motor vehicle crash. This observation was followed by studies that demonstrated significant cell changes in the neck and back muscles of patients with TOS.

Congenital bands and ligaments are observed in a large majority of TOS patients. Several different kinds of bands have been recognized and categorized. These bands and ligaments are present at birth. In patients with TOS, they become associated with symptoms following trauma – even minor trauma. The anatomic findings are, therefore, usually regarded as a pre-disposing factor and not the causative agent.

One would assume that if the site of pathology in TOS is the scalene muscles. There should be abnormalities found in them. In fact, findings of muscle scarring have been found and reported in the medical literature.

Based on the above observations, namely a history of neck or shoulder trauma with variations in normal anatomy and cell changes in scalene muscles, one can readily explain the pathophysiology of TOS. The underlying pathology in most patients is scarring of the scalene muscles caused by shoulder or neck injuries. The tight scalene muscles (due to scarring) cause neck pain and headaches, as well as temporomandibular joint (TMJ) symptoms, which usually develop within a few days of the crash. As scarring in the muscles develops, the muscles compress the brachial plexus (a network of nerves, running from the spine through the neck, through the armpit region and into the arm). The compression elicits the symptoms of pain, numbness, and weakness of the upper extremity.

The onset of extremity symptoms may be delayed a few days to weeks, and in some patients, even months – as it takes time for scar tissue to develop and compress. As the pathophysiology becomes established, scarring adds to the problem. These injuries set up a vicious cycle. Pain, bad posture, poor physical conditioning and anxiety then aggravate that cycle.

In conclusion, the anatomic problems that lead to TOS are now well-known and documented in the medical literature. They consist of congenital anomalies that are superimposed on some fort form of trauma – even trauma caused by low impact forces.

Used with permission from MD Business Consultants.

This is the first post in our series of medical information for attorneys.  We will strive to present medical information and topics which may help attorneys and their clients understand medical concepts, cases, terminology, etc.  We will strive to keep it simple and relevant and I hope that both attorneys and clients might find this information useful in their cases.

Dr. Ron Jolda

PDMG Consulting, LLC