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By E. Franklin Livingstone, MD
The medical specialty of physical medicine and rehabilitation (physiatry), encompasses the diagnosis and treatment of a wide range of medical and physical problems. The problems can be as minor as a sore shoulder or as complicated as a spinal cord injury. The focus of this specialty is on restoring function and quality-of-life to individuals with disabling illnesses or injuries. Physiatrists diagnose and treat acute and chronic musculoskeletal pain disorders as well as disorders of the nervous, muscular, and skeletal systems. They study the appropriate use of various physical medicine modalities, such as heat, cold, exercise, traction, and electrical stimulation for motor development and pain control. Physiatrists are trained to lead a multidisciplinary team of medical professionals in the comprehensive and holistic treatment of illness and injury related disability. Indeed, the specialty of physical medicine and rehabilitation was the first to promote and develop a holistic medical team based on the interdisciplinary treatment of often complex medical, physical, and psychological problems. Many physiatrists receive extensive training in the subspecialty of Electrodiagnosis: electromyography of nerves and muscles and nerve conductivity testing.
Forensic Considerations
Life care planning is complicated by severe physical impairment and multiple complex and progressive medical disease processes. In general, behavioral traits (particularly poor compliance) factor strongly into past progression, current status, and prognostic speculation. Current medical care with extrapolation to future care needs, in light of the progressive nature of the disease processes involved, must be as clearly delineated as possible with coherent justifications. Durable medical equipment needs will also change over time based on the progression of physical impairment somewhat in parallel with disease progression and should be anticipated in the life care plan. Given the somewhat dismal prospects in this case, quality-of-life considerations for the clients and their significant others should be given as much forethought as ongoing medical needs.
Plans for optimizing physical function will be primarily concerned with equipment and environmental modifications as well as prevention of secondary complications including progressive debility. Periodic and ongoing therapeutic intervention for the latter should be anticipated and may require comprehensive services from multiple providers and professional disciplines. The treatment management of these cases requires consideration for continuity, thoroughness, and flexibility in order to respond to the ever-changing medical and physical needs of each individual.
In this day and age, family care or participation may not be an option in patient care. Financial needs over the predicted life span of the client should take into consideration long-term care placement versus home nursing/attendant care and may account for a lion’s share of anticipated costs. Actual needs will depend upon disease and impairment progression, which are also affected by behavioral factors, client and caregiver training, and compliance to treatment recommendations. Worst-case scenarios will be presented, but other less-than-worst-case alternatives should also be considered and planned for.
Vocational issues are not a significant concern in this situation, but many times they are primary issues with respect to damage claims. Potential and actual economic losses are often substantial. Any study of future employability or under-employability needs to include appropriate goals for vocational rehabilitation, costs involved, and a cataloging of available resources. A vocational rehabilitation consultant is recommended to be part of the multidisciplinary team for clients of appropriate vocational age.
There are two separate causation issues in this case. First, did the progression of medical problems leading to bilateral below-knee amputations stem directly from the progression of the sacro-coccygeal ulceration? And second, did the coccygeal skin breakdown result from negligence on the part of the medical staff at the cardiology institute or the acute care hospital where surgery and post-surgical convalescence occurred?
This is a complex case with multiple disease processes, the natural history of which result in progressive problems and secondary complications. The client was discharged to his home with a small, healing coccygeal (actually, lower sacral, S4-S5, and coccygeal) skin breakdown, grade II, with partial skin thickness ulceration. This generally heals with simple conservative wound care and pressure relief. He received home health nursing care.
Healing was thwarted by many factors. The client had a history of poor compliance with positioning changes. He preferred the reclined and supine position, leading to inadequate pressure relief in the area of the skin breakdown. He was on medications that interacted to cause nausea, resulting in inadequate nutrition to facilitate healing. His two significant progressive disease processes (diabetes with associated angiopathy and arteriosclerosis with severe peripheral vascular disease) combined to result in poor blood flow to the area of the skin wound. In this case, too much pressure, inadequate blood flow, and poor nutrition were a recipe for skin ulcer progression. The small lower sacral and coccygeal ulcer gradually progressed, developing a large, deep sacral skin ulceration that eventually required extensive surgical debridement and a skin-flap closure procedure.
The development of skin breakdown at the heels resulted from nearly continuous pressure where the heels rested on the bed mattress (as well as from those factors described previously). However, the ischemic wounds at the toes were not caused by the skin breakdowns but by progressive insufficiency of blood flow to the feet, aided by poor nutrition and a lack of physical activity. This resulted in the death of the skin and subcutaneous tissues along with wound formation that eventually became infected, leading to the necessity of below-knee amputations. While there is a temporal relationship and commonalities in terms of aggravating factors, a causal relationship is not presumable.
With respect to the causation of the initial skin breakdown, which was first noted at admission to the acute care hospital after the evaluation at the cardiology institute, the complaint of “failure to take proper precautions to properly cushion, pad, and protect” the client was not supported by facts. First of all, the client was lying on a flat, padded examination table for about 3.5 hours for the complicated angiographic procedures. This positioning, in the absence of significant physical deformity at the sacrum, would place the client at risk for pressure-related skin breakdown over certain boney areas: the back of the skull, the prominences over the back of the shoulder blades, the heels, perhaps the lateral ankle prominences (if there was significant external rotation of the hip joints), and the upper sacral area. The area involved, the lower sacral and coccygeal area, would be protected from pressure and its detrimental effects under these circumstances by the normal spinal curvatures (see Figure 1). Therefore, on a more probable than not basis, the lower sacral and coccygeal skin breakdown did not occur as a result of any treatment, or lack there of, by the defendants in this case.
That of course begs the question, what caused the initial skin breakdown? On a more probable than not basis, this skin breakdown was, in fact, present at the time of the admission to the cardiology institute, running an indolent course. Its presence and slow development due to inadequate attention to skin care and pressure relief was further facilitated by the client’s poor health and his progressive diabetes and peripheral vascular disease. In addition, the client drove himself to the cardiology institute, a drive of over 3 hours. The position he maintained in his automobile while driving would have caused, more or less, continuous pressure at the lower sacral and coccygeal area. This would have been enough pressure-related impedance to blood flow to cause a subclinical area of skin breakdown to become clinically apparent, as in this case. This timing of progression fits very well into the clinical findings.
In this situation, the physiatrist was able to work with the defense attorney on an ongoing basis, providing periodic updates (written and verbal), helping in trial preparation, providing the attorney with insight into the presentation of evidence at trial, and ensuring that the testimony preceding his testimony set the proper foundation and support for the opinions of the experts involved. The physiatrist was involved in many aspects of the trial casework. He was able to determine the extent and causation of disability; provide support and guidance in all aspects of the life care plan, including beneficial treatment, present and future; and he was able to present evidence that successfully refuted the plaintiffs’ contentions.
The physiatrist will usually have many ideas to offer the attorney regarding the strengths and weaknesses of the case and can help the attorney decide how best to present evidence and testimony to emphasize the strengths of the case based on historical information, injuries, progression of recovery and/or disability, and medical and scientific information sources. The physiatrist, in these cases, is an educator for the involved attorneys, court, and jury, explaining the often complex progressions and interactions involving anatomical structures, physiological processes, and psychological considerations in terms that can be easily understood by non-medical professionals and lay-people. During trial proceedings, the physiatrist is also one of the most qualified witnesses to present objective testimony with respect to non-economic damages, including but not limited to psychological trauma and its consequences, difficulty adapting to specific disabling conditions, and the pervasive effects of chronic pain and its residuals.
As a physiatrist and new member of the American Board of Forensic Medicine within the American College of Forensic Examiners, I would like to increase awareness and understanding of the medical specialty of Physical Medicine and Rehabilitation and the role of the physiatrist in forensic medicine.
References
Burke, W. H. (1995). Forensic rehabilitation. Houston, TX: H.D.I. Publishers.
Deutsch, P. M. (1990). A guide to rehabilitation testimony: The expert’s role as educator. Orlando, FL: P.M.D. Press.
Weed, R. O. (1999). Life care planning and case management handbook. Boca Raton, FL: C.R.C. Press.
Livingstone, E. F. (2004). Current issues in the field of forensics: An introduction to forensic physiatry. The Forensic Examiner, 13(4), 62-63.
About the Author
E. Franklin Livingstone, MD, was born and raised in Seattle, Washington. His interest and passion for rehabilitation medicine developed after his own experience in rehabilitation. At the age of 18 and 2 weeks before graduating from high school, Livingstone was injured in an automobile accident. He was thrown out of one car and landed on the front bumper of another, fracturing his lumbar vertebrae and damaging most of the nerves in his legs. He spent 5 months recovering in the University of Washington Hospital, attended to by a very special physiatrist, Dr. Donald Silverman. Dr. Livingstone’s desire to pursue a career in rehabilitation medicine developed over the next 6 years, and he subsequently matriculated through his undergraduate, medical school, and residency education at the University of Washington. He graduated as a rehabilitation patient in 1967, and he graduated his training as a physiatrist in 1983 from the same rehabilitation program. Currently, Dr. Livingstone is the Director of Rehabilitation Medicine at Havasu Regional Medical Center where he is living out his dream of being a rehabilitation doctor and connecting with patients as Dr. Silverman did with him. Visit his website at www.doctor-livingstone.com.
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I am proud to work with the courses and articles conceived and written by dedicated professionals who have made it their living to help heal, defend, serve, protect, and save their fellow citizens from terrorism, criminals, mental illness, disease, and so many other world problems and pandemics. I have reviewed dozens of resumes and curriculum vitae for my peer reviewers and course authors. Their degrees, credentials, and experience speak for themselves of the excellence embraced and exuded by the associations.
Under the umbrella of the American College of Forensic Examiners International, I have reviewed and edited articles that discuss cutting-edge research written with government agents I interviewed in person at Quantico; I have met forensic legends Dr. Cyril Wecht and Dr. Henry Lee (both long-time ACFEI members); and I get to see to completion the modules and coursework that are born of the passion of many prominent individuals from an array of important fields. I know for a fact that the continuing education curricula individuals like these and others help create are forged from impeccable research, training, and consultation. These people are far too intelligent, prestigious, and philanthropic to waste their time with lesser organizations; Dr. Robert O’Block’s ACFEI stands only for legitimacy and professionalism.
What is it that draws so many—nurses, physicians, soldiers, investigators, government employees, psychologists, psychiatrists, social workers, and a sheer multitude of other honorable professions—into the American College of Forensic Examiners Institute fold? Decide for yourself, as thousands wisely did before you:
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As we continually improve our continuing education coursework, Web presence, and printed publications, that growth is bound to continue. The fields in which our members work, study, and fight—homeland security, all areas of forensics, integrative medicine, and psychotherapy—are not going anywhere anytime soon, and are dynamic and ever evolving. When you join the American Board for Certification in Homeland Security, the American Association for Integrative Medicine, the American Psychotherapy Association, or the tried-and-true American College of Forensic Examiners Institute, you will see that we rise above the competition in offering continuing education excellence. Dr. Robert O’Block has created a unique opportunity for you to meet like-minded professionals to network, learn, and teach one another and the world at large.
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The American College of Forensic Examiners International began in 1992; it is still here. Most membership associations rise and fall in less than a decade, but the passion of ACFEI’s founder, Dr. Robert O’Block, and the thousands of reputable people his associations help each year, has fueled continued growth since ACFEI’s inception nearly two decades ago.
As we continually improve our continuing education coursework, Web presence, and printed publications, that growth is bound to continue. The fields in which our members work, study, and fight are not going anywhere anytime soon, and are dynamic and ever evolving. When you join the American Board for Certification in Homeland Security, the American Association for Integrative Medicine, the American Psychotherapy Association, or the tried-and-true American College of Forensic Examiners Institute, you will see that we rise above the competition in offering continuing education excellence. Dr. Robert O’Block has created a unique opportunity for you to meet like-minded professionals to network, learn, and teach one another and the world at large.
To learn more, please visit www.acfei.com.
What is it that draws so many—nurses, physicians, soldiers, investigators, government employees, psychologists, psychiatrists, social workers, forensic examiners, and a sheer multitude of other honorable professions—into the American College of Forensic Examiners Institute fold? Let me share with you just a few of the numerous reasons so you can better decide for yourself, as thousands wisely did before you:
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By Leann Long, BS
A Tragedy Unfolds
On the morning of February 2, 2002, the parents of Danielle van Dam were forced to face their worst nightmare when they discovered the empty bed of their 7-year-old daughter. Danielle was last seen the night before when Damon van Dam put his beautiful blue-eyed daughter to bed. The distraught parents immediately reported Danielle as missing, and an extensive search involving hundreds of volunteers began. Authorities assumed that the innocent young child was abducted from her bed while she slept on the night of February 1, 2002.
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