Sample Case Descriptions

LIFE EXPECTANCY:

A thirty-five-year-old male sustained thermal burns over 90% of his body surface area. The patient also developed cerebellar atrophy, left ventricular dysfunction, and hypertension. Following a hospitalization of two-hundred and seventy days, the treating burn surgeon predicted a normal life expectancy of an additional 41.8 years, (76.8), and lifetime medical expenses were estimated at $53 million. Calculations derived from a detailed physiologic analysis of the multi-system organ pathology indicated that life expectancy was likely to be five-ten years.

A forty-four-year-old male with chronic liver disease secondary to autoimmune hepatitis suffers anoxic brain injury during upper GI endoscopy and subsequently dies. The issues to be determined in this case included how much this patient’s life expectancy was reduced secondary to his chronic liver disease and how long he would have lived absent his respiratory arrest during upper GI endoscopy.

A fifty-five-year-old female with breast cancer experienced a two-year delay in treatment. The patient had a history of obesity, hypertension, and obstructive sleep apnea. The issues to be determined in this case include how her non-malignant medical problems impacted her life expectancy and how much her life expectancy was reduced secondary to the two-year delay in the treatment of her breast cancer.

A fifty-six-year-old male with numerous medical conditions developed paraplegia following surgical evacuation of an epidural abscess. The patient had a history of alcohol abuse, insulin–dependent diabetes mellitus, hypertension, obstructive sleep apnea, chronic obstructive pulmonary disease, obesity, and chronic renal failure. Calculation of physiologic age based on multiple medical problems revealed marked reduction in life expectancy of less than five years, as opposed to a twenty-two-year life expectancy based on the Social Security actuarial tables. The issue to be determined was the probable life expectancy of this patient absent the surgical procedure.

A thirty-four-year-old female with a history of insulin-dependent diabetes mellitus was involved in a motor vehicle accident, resulting in blunt head trauma and acute respiratory failure. Prolonged mechanical ventilation resulted in tracheal stenosis requiring treatment with laser therapy and tracheal stent placement. The issue to be determined was what this patient’s life expectancy would have been absent the motor vehicle accident.

A sixty-two-year-old truck driver was involved in a fatal motor vehicle accident and died instantly. Careful review of records revealed a complex medical history consisting of hypertension, diabetes, peripheral vascular disease, coronary artery disease, chronic obstructive pulmonary disease, and obesity. The issue to be determined was how long this patient would have survived absent the motor vehicle accident.

CAUSATION:

A forty-two-year-old male who underwent elective ascending aortic resection and aortic reconstruction developed uncontrolled bleeding. An emergency coronary artery bypass graft was performed and the patient received voluminous blood products. During the procedure, the patient suffered a cardiopulmonary arrest and could not be resuscitated. The postmortem study showed hemorrhagic areas in the posterior wall of the left ventricle. The issues to be determined were the specific mechanism of death and the cause of the myocardial hemorrhage.

A twenty-nine-year-old female with a history of asthma suffered a cardiopulmonary arrest during elective laparoscopic tubal ligation, incurring anoxic brain damage. Careful analysis of anesthesia records revealed a gradual drop in blood pressure and oxygen saturation. An echocardiogram revealed a severely reduced left ventricular ejection fraction of 25-30%. The issues in this case included whether the patient suffered from peripartum cardiomyopathy, anaphylaxis from intravenous medications, or mismanagement of the patient’s airway.

A sixty-year-old male died from a pulmonary embolism. This patient had previously suffered a traumatic below-the-knee amputation of the right lower extremity, and had a previous diagnosis of prostatic cancer. The issue in this case was whether the patient’s fatal pulmonary embolism was secondary to a reduction in activity following the amputation or whether it was due to prostatic cancer.

A twenty-four-year-old female presented with symptoms of pneumonia. The patient was treated with antibiotics but developed acute respiratory distress syndrome (ARDS). The patient underwent fiber-optic bronchoscopy and transbronchial biopsy and subsequently developed a pneumothorax. A chest tube was inserted and the lung was re-inflated. The patient eventually died of complications of multisystem organ failure. The issue to be addressed in this case was whether the pneumothorax either caused or accelerated her ARDS and/or multisystem organ failure, contributing to her death.

A fifty-six-year-old female with a complex medical history was intubated for an episode of acute respiratory failure due to pneumonia. A distorted tracheal anatomy due to severe scoliosis, diaphragmatic hernia, and a hypoplastic left lung resulted in perforation of the trachea. The patient died from complications associated with tracheal damage following intubation. The issue to be determined was how perforation of the trachea occurred during a routine intubation.

A thirty-three-year old female involved in a motor vehicle accident sustained chest and abdominal trauma resulting in liver laceration. The patient developed hemoperitoneum and acute respiratory failure requiring intubation and mechanical ventilation. Abdominal surgery and liver repair were done successfully. The patient subsequently developed progressive respiratory distress after being extubated and suffered fatal cardiopulmonary arrest. An autopsy revealed four liters of fluid (chyle) in the left chest cavity and chylothorax to be the likely cause of death. The issue to be determined was the mechanism of death as well as whether it was avoidable.

A fifty-one-year-old male with a history of mental retardation died while eating a burrito. An atypical history for upper airway obstruction prompted a careful analysis of the patient’s medical records, which revealed a history of cardiac arrhythmias (atrial fibrillation and high-degree atrioventricular block) that could not be treated by ablation. The issue to be determined was the proximate cause of death; specifically, whether his death was due to acute upper airway obstruction, or was secondary to fatal cardiac arrhythmia.

PRE-EXISTING CONDITIONS:

A fifty-six-year-old female suffered tracheal perforation during endotracheal intubation. The patient had numerous premorbid conditions, including severe scoliosis, large diaphragmatic hernia, right lung hypoplasia and diaphragmatic paralysis. The trachea could not be repaired and the patient died of acute respiratory failure. The issue to be determined in this case was whether the tracheal perforation was avoidable given the severe torsion of the trachea related to her distorted chest anatomy.

A fifty-year-old male developed “short bowel syndrome” after numerous abdominal surgeries following catastrophic abdominal injury. The patient died of sepsis four years later following a postoperative course involving numerous complications. A careful review of medical records revealed evidence of coronary artery disease, alcoholic liver disease, chronic obstructive pulmonary disease, and recurrence of lymphoma. The issue to be determined was whether this patient’s numerous pre-existing conditions impacted his survival.

A forty-six-year-old male was diagnosed with fungal pneumonia secondary to blastomyces, which ultimately proved fatal. Medical records revealed a history of stroke, COPD, and coronary heart disease, as well as a long history of nicotine, cocaine, and alcohol abuse. The issue to be determined in this case was the degree to which the patient’s clinical course was impacted by the preexisting conditions.

APPORTIONMENT:

A sixty-three-year-old male with numerous medical problems was involved in a motorcycle accident, suffering numerous chest injuries, resulting in a severe level of disability. The issue to be determined in this case is the contribution of his numerous premorbid medical problems, including severe COPD, severe peripheral vascular disease, and diabetes, to his current level of disability.

A thirty-year-old female underwent mastoidectomy for chronic mastoiditis. The procedure was complicated by sigmoid sinus thrombosis resulting in quadriplegia due to severe cerebral edema and herniation of cerebellar tonsils. The patient was subsequently noted to have a positive lupus anticoagulant. The issue to be determined in this case is the contribution of her lupus anticoagulant to her sigmoid sinus thrombosis.

A sixty-year-old female with a diagnosis of mesothelioma had a history of secondhand exposure to asbestos (from her husband’s work clothing). An analysis of particle exposure revealed minimal exposure during periods of coverage. The issue to be determined in this case was what the contribution of the particle burden (exposure to her husband’s clothing) was to the pathogenesis of the malignant tumor.

A seventy-two-year-old male suffered an esophageal perforation during upper GI endoscopy and eventually died. A review of medical records revealed that the patient had an eighty pack a year smoking history, as well as chronic obstructive pulmonary disease. He also had a history of diabetes mellitus, hypertension, and congestive heart failure. The question in this case was whether the esophageal perforation hastened this patient’s demise.

A sixty-year-old male sustained blunt chest trauma and acute respiratory failure secondary to a motorcycle accident. Prior medical history included hypertension, coronary artery disease, chronic obstructive pulmonary disease, and peripheral vascular disease. The issue in this case was whether the chest trauma from the motorcycle accident aggravated his chronic obstructive pulmonary disease and/or shortened his life expectancy.