Pressure Ulcer Prevention and Treatment

Posted on June 30, 2008 by Charles Cerussi

Nursing homes and other long term care facilites have become the focus of scrutiny because of increasing improper care, negligence and failure to prevent pressure ulcers. Patients are caused to suffer pain, disfigurement, decreased quality of life and increased risk of illness and death from pressure ulcers that exist due to the negligence of the healthcare provider and often lead to legal action. Pressure ulcers, or decubitus ulcers, occur when bedridden patients are left in one position for an extended period of time, preventing the patient's weight to be shifted to avoid pressure. The area of skin that comes in contact with the bed, wheelchair or other object is caused to break down due to the constant pressure and ultimately, the tissues die because of the reduced blood flow to that area.

Pressure ulcers are categorized by severity from Stage I to Stage IV and range from a reddened area of the skin to an ulcer so severe that the muscle and bone, and often times the tendons and joints, become damaged.

Some preventive strategies involve the implementation of patient education, clincian training, strategies in developing communication and terminology materials, provision of toolkits and protocols, behavioral challenges and healthcare provider and patient adherence. Educating patients and their families about wound care and training health care providers in preventing the pressure ulcers is crucial to the prevention. Documentation should be provided to health care facilities and providers which will ensure that they become familiar with all the terms and vocabulary of pressure ulcers and prevention as well as ensure that they develop better skills in sharing information with one another. Toolkits and protocols are also important in that they provide documentation of pressure ulcer staging along with protocols for care and training materials for clincians carrying out the protocols. Behavioral challenges promise to transform acute care pressure ulcer prevention within a short period of time and healthcare provider and patient adherence and compliance will become the vehicle which drives the pressure ulcer prevention strategies.

As prevention strategies and interventions are underscored as a solution to this problem, recognition and education of the pressure ulcers remain the initial significant component of the clinical care of wound treatment.

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Establishing Conscious Pain and Suffering in New York and New Jersey

Posted on June 18, 2008 by Charles Cerussi

A common problem in wrongful death actions in New York and New Jersey is that neither state allows for compensation for what usually is the greatest loss to the decedent's family, namely the emotional grief and distress that is attendant with losing a loved one.  Both New York and New Jersey limit damages in wrongful death cases to "economic loss" to the decedent's estate, as well as conscious pain and suffering that was experienced by the decedent prior to his or her actual passing.  Accordingly, it is imperative for attorneys practicing in these states to develop evidence establishing conscious pain and suffering.  This is done by retaining either an expert in critical care medicine and/or a forensic pathologist to review the medical records and the entries of any nurses and/or physicians, as well as the testimony of any witnesses to either an accident or persons who were with the decedent after an act of malpractice was committed.

Conscious pain and suffering awards can be substantial in wrongful death actions and can offset the injustice of the wrongful deaths acts in New York and New Jersey.  By way of example, a jury awarded $2 million for conscious pain and suffering in a medical malpractice action, which award was affirmed by the Appellate Division in New Jersey in 2006.  The jury's award for pain and suffering was for only four (4) minutes of suffering that occurred after the decedent's doctors failed to properly drain his gastric contents, causing the patient to choke to death on his own vomit.  The death was described as "horrible," as if the decedent were "drowning" in his own secretions.  Accordingly, under these circumstances, both the trial judge and the Appellate Division did not find the pain and suffering award excessive.

Therefore, it is clear that the conscious pain and suffering component of a wrongful death action is critical in most cases and can serve to offset some of the inequities of the current wrongful death acts in both New York and New Jersey.

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Brachial Plexus-Erb's Palsy Injury with Shoulder Dystocia During Childbirth

Posted on June 18, 2008 by Charles Cerussi

Shoulder dystocia occurs during childbirth when after the head of the child is delivered, the anterior shoulder of the infant cannot pass below the pubic synthysis.  It is diagnosed when the shoulders fail to deliver spontaneously after the fetal head.

It is imperative that during the management of shoulder dystocia that the attending obstetrician not apply excess downward lateral traction, which can cause a brachial plexus injury.  Excess lateral traction is the most common cause of brachial plexus injuries and its utilization fails to meet standards of care and can result in the baby being delivered with Erb's Palsy.  Traction on the head that is applied by the OBGYN at delivery can cause brachial plexus nerve injury.

Fetal maneuvers can reduce the incidence of bracial plexus palsy and are both safe and effective.  It has been described by Drs. Gurewitsch and Allen of the Johns Hopkins University School of Medicine that fetal manipulation is actually associated with a very low rate of injury compared to maternal maneuvers or traction alone.  Because of this, training in fetal maneuvers should be emphasized and should be prioritized in shoulder dystocia management algorithms.

Drs. Gurewitsch and Allen advised that clinicians need to think counterintuitively - to slow down, but keep track of time and use it wisely.  OBGYNs are advised to wait for a contraction, but not to push or pull, instead allowing the shoulders necessary time to rotate on their own.  They should actively increase their awareness of traction and their tendency to naturally increase it when faced with a difficult delivery.  Use of episiotomy should be only to gain access to perform fetal maneuvers and not as a maneuver in its own right.

Finally, Drs. Gurewitsch and Allen advise that obstetricians are urged not to fear fetal manipulations but rather to become adroit at them, by practicing on all shoulder dystocia delieveries and even on routine deliveries.  Researchers, educators and policy makers need to validate, prioritize and re-emphasize the advantage of fetal maneuvers for management of shoulder dystocia.

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