We received many entries and would like to thank all of you who have contributed over the year. We are unable to post all of the entries due to the overwhelming response. We are posting the winners and a few of our favorite responses.   Click each person's name below to see their response. FIRST PLACE WINNER: Sue Brown, IA She has been a nurse since 1993 and is a CLNC®. Sue entered the contest in order to get some experience and learn the areas where she needed to improve her case study skills. She became a Legal Nurse Consultant after her youngest son was in a car accident while on his way to work with two of his friends; two of which were killed. She worked with the attorney on the case and liked the correlation between the legal and medical aspects. She became certified and is in the process of developing her own Legal Nurse Consulting business.     SECOND PLACE WINNERS: Sheryl A. Warner, FL Sheryl has been a nurse for over 20 years. She is a Licensed Healthcare Risk Manager, Case Management Specialist, Forensic Nurse Specialist, and Legal Nurse Consultant. Jane Hurst, OH Jane has been an RN for almost 25 years and Legal Nurse Consultant for over 12 years.   OTHER GREAT RESPONSES: Kirk Herbert Kirk had a well thought-out response. Henrietta Garramone Henrietta saw it from the other side bringing us a new perspective way to look at the case. Ben Chapman Ben gave us his response as a Consumer Protection Investigator. SCENARIO: The case of the Tow Truck T-Bone    This case involves a motor vehicle collision. The side collision occurred at an intersection where a tow truck collided at the driver's location. The driver of the tow truck, Gus, was at fault according to the police report. The driver of the tow truck was not injured.   The occupant that was injured was driving a Honda Civic. Her name is Linda. Linda is a 39 year old woman, with a 7 year old daughter. She is married. Linda, stepped out of her car, walked into a store, used the phone and called her husband. While she was on the phone, she was apprehended by the police who smelled alcohol on her breath. The police asked her if she wanted to go to the hospital and Linda stated that she thought she was fine and did not want to go.   Linda's husband, Anthony, arrived on the scene and asked why she was not in the hospital. The police explained that Linda did not think she needed to go to the hospital. Anthony exclaimed, "What, you don't think she needs to go anyway, did you see what she looks like!" Linda at that time fell to the ground. Based upon the severe damage to her car, the way her husband was acting, and Linda falling to the ground, EMS  took Linda to the hospital. She was diagnosed with a Hangman's Fracture.   The hospital drew blood and the doctor told her that her blood alcohol level was below the legal limit of 0.08.    All the necessary precautions were in place for Linda at the hospital. Linda had Anthony call her attorney regarding what happened to her.   Her attorney contacts you and tells you he visited Linda in the hospital. The doctor has told Linda she will be undergoing surgery to repair a Hangman's Fracture, and she has an 80% chance of being paralyzed after the operation. The Lawyer said she was wearing a Halo device, appeared to be in a lot of pain, had significant frontal bruising on both of her legs just below her knees, was able to move all of her extremities and was able to talk normally. The only sign of paralysis was that she did not have any feeling on the top of her head. The attorney was concerned with the likelihood she might not be able to communicate with him after the operation.   Does the case have merit? Who would you think could be listed on the lawsuit? What other injuries could Linda have? What health consequences could result from a "Hangman's Fracture" severe enough to require surgery? Is there any risk of death, paralysis, etc...? What records do you think will be needed? Will there be any experts needed on this case? Which type of experts? What other information would you ask for? What medical information could you provide?   What additional advice or suggestions do you have for the attorney?   What could you do to help the attorney win this case? How would you prepare as a Legal Nurse Consultant handling this case?   SUE BROWN'S RESPONSE After reviewing the information provided, it is my opinion that the case in question is meritorious. The truck driver struck the car with the client on the driver’s side and the police also verified that he was at fault in their accident report. Potential Defendants: Gus, the truck driver The company Gus works for The people that contracted for Gus’s service, if any The police officers The city and/or county that employ the officers The EMTs, if on the scene before the client was removed or got out of the car The company that the EMTS work for or contract them The Fire Department rescue workers, if used to extricate the client from the car The city or county to which the Fire Department belongs Also, it would be helpful to know if your client had her seat belt on It would also be a good idea to obtain medical records of the truck driver, both past and at the time of the accident. Depending of the time of day and whether the truck driver was working or not. Was any alcohol detected in his system? Did he have valid insurance? Possible Other Injuries: Concussion; due to the compliant of numbness and the force of impact that was great enough to cause the C2 Fracture. A common type of head/brain injury is the combination coup and countercoup. Intracranial bleeding and/or swelling, also from the force of impact. Rib fractures, possible hairline or non-displaced. Injuries to the knees and the lower legs, as evidenced by the significant frontal bruising on both legs below the knees: Tearing of the ligament and tendons that support the knee joint. Tearing of the cartilage that support and add in the pivot movement of the joint. Fractures not readily seen if there is swelling in the joint and upper and lower legs. Dislocation of the hips, from the impact that caused the bruising of the frontal legs. Compression or dislocation of the left shoulder joint, from the force of the collision. Might also want to know if she was expecting a baby, or if she and her husband intended to have another child. The client is 39 years old, but still in her child bearing years. Some couples have children in their late thirties and early forties. Health Consequences that can result from the Hangman’s Fracture: The primary consideration is the possible death of the client, or paralysis. This fracture affects the spinal cord above the level that allows for independent or spontaneous breathing. This will depend on how much of the spinal cord is damaged and at what location. It will also depend if there are any bone fragments in the spinal cord cannel or that have penetrated the spinal cord itself. The information provided states that there is an 80% chance of paralysis. In all likelihood, the client will have no use of her arms or legs, will have to be on the ventilator and have no verbal communication abilities. A Neurology Specialist will be able to explain in more detail. The other systems of the body that will be affected by the paralysis from the spinal cord injury will include but not be limited to: ·        The Respiratory System, not just the ability to breath on her own, but also the increase risk of infections, aspiration, and compromised autoimmune system. ·        The Cardiovascular System, due to injury of the vagus nerve, resulting in either increased or decreased blood pressure and bradycardia. ·        Thermoregulation, or the ability of the body to respond to temperature changes of the environment and internal factors. ·        The GI tract will be affected by the fact that she will no longer be able to take in nutrition by mouth. One type or other of gastric tube will be needed to supply nutrition and liquids long term, life long. The intestinal tract will also be affected and she in all likelihood will need help with fecal elimination, and have frequent episodes of constipation. ·        The GU tract will have no muscle tone and she will need to have an indwelling catheter placed in her bladder to allow for removal of urine. This will increase the risk to bladder and kidney infections. ·        Pressure ulcers, due to the loss of her ability to move her arms, legs and the rest of her body independently will increase the risk of pressure point and will compromise the integrity of her skin. ·        Atrophy of the muscles will also be a factor and could result in the need for additional surgeries to cut tendons to release joints that will develop contractures. ·        Sexual dysfunction can also occur. ·        The client’s psycho-social well-being will also be affected resulting in bouts of anxiety, grief and depression. ·        Damage to the vagus nerve conduction will affect the function of all organs, from the pharynx, larynx, respiratory, lung down to the large intestine. Records to be obtained (but not limited to): The police report of the accident, also eyewitnesses, if any, and the Fire Department or rescue reports. All hospital records, trauma, X-ray, laboratory, MRIs, Cat-scans, Neurologist assessment, and the Dr. Consultants from all that have had or been called in to evaluate the client. You may also want to request any and all old medical records, to compare and check for any preexisting conditions, or injuries to head, neck, back, knees, etc… You will also want to get copies of the policies and procedures for the police department, the ambulance and EMTs. Also the Trauma and hospital policy and procedure and Standards of Care for the Trauma and X-ray and floors that cared for the client. You will know to obtain the medical records of the truck driver, both past and from the day of the accident, and his driving record. Experts: Neurosurgeons Rehabilitation Specialists, physical, occupational and speech therapists Psychologists Social Workers Physicians of internal medicine A Life Care Planner Respiratory and Cardiac, physicians Dermatologist Additional information that you will want to start to gather will be, but not limited to: The projected medical equipment needs The amount of income that will be lost, if the client was employed, will need to be determined. Childcare needs, whether she worked, was a stay at home mom or if her husband has a job that required him to go out of town for business. Determine if there are other family members, in good health, that can and will help. What kind of support system does this family have? Some thought also needs to be given regarding family counseling. Medical information I can supply: Give more in-depth report explaining the dynamics of the fracture, and how the various systems will be affected. What the chances are of recovery and degree of that recovery. Family counseling will be needed, whether your client does or does not survive the surgery. Determine the type of rehabilitation facilities that are available, as well as accessibility and location of long term facilities. Assist with the gathering of the demonstrative evidence for trial, diagrams or skeletal props that will show the areas of injury and can be disassembled to show juries how the mechanics of the body works. Work with Life Care Planner to develop a “Day in the Life” video that will demonstrate the quality of life for the client after. Assist with the development of the interrogatories and questions for screening potential jury members. Organize the medical record into chronological order and explain and decipher the medical notes and abbreviations. Defines all medical terminology; for example, coup and countrecoup. I would also recommend that you obtain as much verbal information and feeling from your client as possible because of the very real possibility that she will either not survive the surgery or will be unable to speak afterwards. To help with this case, I would help the attorney develop a very real, visual picture of how the client and her family’s life has been forever changed.       SHERYL WARNER'S RESPONSE: 1)      Merit: Yes, the case has merit. The truck driver (Gus) was cited to be at fault according to the police report. It would be up to the defense to prove otherwise. He either ran a stop sign or a red light to strike the drivers side of the Honda Civic (small car). Elements: Failure to use reasonable care while operating a tow truck resulting in MVA. Causation could prove to be tricky due to the fact that Linda got out of the car and entered a store to call her husband, instead of staying still until EMS arrived to perform an assessment, thus comparative negligence may play a part in causation. 2)      Possible Parties Listed in the Lawsuit: Tow truck company Gus Police Department and/or the officer who apprehended her Possibly the EMS, if she was not placed in the cervical collar or backboarded for transport City and/or County if there were any road hazards etc…and if there were, then the construction company handling the road renovations 3)      Possible Injuries/Injuries: Hangman’s fracture of the cervical spine (known), possible paralysis, nonunion, malunion, pseudoarthrosis formation, neurovascular injury, infection, hardware failure Respiratory malfunction/trach/vent Subdural hematoma or other head/brain injury Fractures – facial, pelvis, extremities, skull Internal injuries/hemorrhaging and/or ruptures/contusions 4)      Records Request (on both Gus and Linda): Pat medical records going back 10 years Employment/salary records Police report and any subsequent reports, policy and procedures Background checks, recorded statements EMS report, policy and procedures Hospital records and the records of all treating physicians All medical bills and other expenses related to the accident Driving history records Insurance information from both parties, as well as the towing truck company, police, and EMS insurance information 5)      Experts: Liability Experts and Causation Experts: accident reconstructionists, forensic anatomist to testify regarding causation of injury; biomechanical/biomedical engineers to analyze effects of various forces involved in MVA collision; human factor engineers, EMS, possibly police officer on standard procedure involving MVA with expected injuries. Damage Experts: Vocational experts, life care planning experts, economists, life expectancy experts, truck experts. 6)      LNC Role: Analyze the medical records of both parties to look for any inconsistencies in descriptions or information provided by Gus (maybe Gus had a seizure disorder that he failed to disclose to his employer and he should not have been driving, etc…). A drug test should have been performed on Gus at the time of the accident, etc… Educate the attorney on any medical conditions, anatomy and physiology Transform the information in the medical records into a format useful to the attorney Perform searches of the medical literature Assist with discovery process Interview clients Assist with trial prep, locating witnesses, attend IMEs, testify as an expert fact witness, assist in preparing settlement documents 7)      It will take an expert to determine whether or not alcohol played a significant role in this accident and/or if this accident was preventable. Alcohol affects everyone differently. I am sure this will be a mitigating factor for the defense. As for the injuries, the case for the plaintiff would have been a lot stronger had she not gotten out of the car and walked into the store – it may be difficult to prove that the Hangman’s fracture was a result of the MVA as opposed to the fall and striking her head, since she was able to get out of the car and walk to the store and call her husband. She may have suffered other injuries that caused the fall; internal bleeding causing her to become faint and fall, striking her head this resulting in the cervical fracture. A Hangman’s fracture can be the result of an MVA, falls or other injuries leading to hypertension or vertical compression of the neck. Therefore, the neck injury may be comparative negligence; however, if there were in fact internal injuries leading to her falling, this can be casually related to the MVA. Did the policeman have a duty to keep her calm (knowing accident victims are frequently in a fog and unable to respond appropriately and often respond instinctively)? This information may be found in the policy and procedure manual form the police station. Certainly, there is a lot of discovery that would need to be done as well as an investigation and possible incident reconstruction to get the facts of this case. This was a very interesting case with a lot of unanswered questions.       JANE HURST'S RESPONSE: Merit? Yes, this case does have merit, however, there are some areas that may be problematic. Who should be named in the lawsuit? The towing company; The tow truck driver, Check out other possibilities. Other possible injuries? Additional fractures; Vertebral artery injury; Internal injuries; obvious contusions of the lower legs bilaterally. Health consequences related to Hangman’s Fracture/risk of death, paralysis? Immediate consequences are related to the surgery itself. If there is damage to the vertebral artery or transverse ligament rupture, there could be brainstem ischemia. This could result in respiratory arrest and the inability to breathe independently. Death is possible. The surgical repair may also disrupt what little stabilization has been achieved and result in permanent quadriplegia. Records to request? 1. Tow truck driver’s driving records (has he been involved in other accidents?) 2. Tow truck driver’s medical records (does he have a significant past medical history of pre-existing conditions that could account for this accident?) 3. Linda’s present medical records 4. Linda’s past medical records 5. Linda’s emergency squad records 6. Linda’s driving records Experts and which type? Yes, there are a variety of experts that would be needed for this case. 1. Neurosurgeon 2. Physiatrist (rehab physician. Depending upon outcome of surgery) 3. Physician specializing in cervical neck injuries 4. Life Care Planner Additional information to request? 1. Was the child in the car injured? 2. Linda’s profession, if any 3. Are there any other children and how many 4. Why was Linda drinking? Medical information to provide the attorney: I would compile research pertaining to Hangman’s Fracture. (The same injury Christopher Reeve’s suffered) I usually make sure that this information isn’t too technical. I also provide diagrams or drawings of the area. I try to educate the attorney about the condition as much as possible. Additional advice/suggestions for the attorney: As I mentioned before, there are some defenses in this case. Number one would be that Linda had been drinking. It could be argued that if she wouldn’t have been under the influence of alcohol (even though her level was below the legal limit), she would have used better judgment after the MVA. She may have remained in the car and awaited emergency treatment. She may not have refused medical treatment. In the research, it mention’s that improper use of the seatbelt could result in a Hangman’s Fracture. The seatbelt may not have been used properly. This could be something that Linda would do every time she drove, or it could be because she was drinking. How to help the attorney win the case? I would like to meet Linda as well as her family, if possible. I would concentrate on Linda’s life before and after the accident. This will show the direct impact the MVA has had. Prior to surgery, he could make arrangements with a videographer, to film a “Day in the Life of” video. If this case ends up in a court, it provides an authoritative physician on neck fractures. The use of a MVA reconstruction consultant may be able to deduce that the accident would have occurred the way it did regardless of Linda’s minor alcohol impairment. Family photographs/videos. Effective communication between the CLNC® and the attorney is essential. Legal Nurse Preparation? I would first establish with the attorney what expectations he has for me pertaining to this case. I would define my duties (screen, opinion, report?) It is important to get the “business” taken care of (retainer etc…) I would try to meet the plaintiff and her family. I would make sure that I have all of the necessary medical records. Research would definitely be a large portion of the preparation. Not only medical research, but researching for experts. I believe that one of the most important segments of working on a case is good communication with the attorney and their paralegal/secretary. Thank you for this case exercise. I’m sure that after I send my answers to you, I will think of something else! I enjoy your site and all of the information. The graphics are wonderful. You are really on the right track with your business.       KIRK HERBERT'S RESPONSE: This case has merit from a personal injury point of view and I would list the driver, Gus as a defendant. Secondly, I would list the Police department and the officer as defendants for not having EMS fully check Linda out at the scene prior to her collapsing. This would be due to the extensive damage to her vehicle and if the officer did in fact suspect her of being intoxicated, the officer should have deemed her incapable of making a safe judgment of refusing EMS care. There might be a potential involvement of the Neurosurgeon and the Hospital depending on the findings found in the medical records and the necessity of the surgery. As far as other injuries that Linda could have, would be the following: 1)      Bilateral leg fractures 2)      Left side thoracic injuries including broken ribs, cardiac contusion, pneumothorax 3)      Concussion/closed head trauma 4)      Pelvic injury including fracture 5)      Abdominal injuries Health consequences that can result from a “Hangman’s Fracture” that is severe enough to require surgery may include: 1)      Quadriplegia or paraplegia 2)      Ventilator dependency 3)      Neurogenic bladder requiring either frequent catheterizations or continuous Foley catheter. Increasing risks for bladder and systemic infections 4)      Bed ridden if quadriplegia or wheel chair bound if paraplegia 5)      If bed ridden or wheel chair bound there would be high risk for multiple episodes of skin ulcers with possibilities of surgical intervention and increased risk for infections 6)      Death 7)      Requirements for feeding tube if unable to swallow 8)      Extremity contractures if paralyzed. Requiring physical therapy 9)      Losing the ability to speak 10)  Losing bowel control requiring digital stimulation 11)  Life time of neurological pain 12)  Psychological trauma 13)  Paresthesia 14)  Muscle weakness 15)  Reflex loss 16)  Sensory loss 17)  Radiculopathy 18)  Increased risk of future hospitalizations and home health related to the complications My evaluation of the necessity of surgery at this time would depend on reviewing the radiological reports and the Physician’s assessment. If this fracture were stable enough to postpone surgery given the fact that Linda’s only symptom was pain and the loss of feeling to the top of her head I would wait to perform the surgical procedure, especially with the 80% chance of paralysis. If there were nonunion of the odontoid with dens displacement of greater than 6mm or greater than I would agree with the early surgical intervention. The treatment with the Halo is appropriate in either case. I would request the following records: 1)      Police report 2)      Any witness statements 3)      EMS report 4)      Complete hospital records 5)      Statement of husband to include a description of Linda at the scene 6)      Past medical records The Expert Witness list would include: 1)      Police officer to testify to Policies for impaired victims of a motor vehicle accident and their waiver of EMS. 2)      Radiologist 3)      Neurosurgeon 4)      Life Care Planner 5)      Physical Therapist 6)      Occupational Therapist The medical information that I can provide the Attorney would include educating them on the mechanism of injury, expected outcomes, treatment options with literature to support those options, current literature, and possible acute and chronic complications. I would suggest that the Attorney get a second opinion for the necessity of the surgical intervention if the surgery has not been done already. I believe that I could help this Attorney win the case by providing them with a current literature search regarding current treatment options and outcomes. I would also assist with finding the necessary expert witnesses; provide them with a comprehensive report to include all of the above-mentioned records. I would prepare by utilizing my critical care knowledge and review current literature, speaking with my Neurosurgeon contacts for a preliminary opinion as to interventions and outcomes. I would also draft up a brief care plan for the next year that would include current complications and potential complications.       HENRIETTA GARRAMONE'S RESPONSE: I don’t think the case has merit. I think she caused the accident. She refused treatment at the scene, and left the accident scene – contributory negligence. EMS cannot force a victim to be treated or go to the hospital. No field sobriety test administered by the police when they suspected DUI. By the time she had a blood alcohol done at the hospital, enough time had passed that the alcohol had probably been metabolized. No evidence of what tests were done to determine dx, and if she was evaluated by a neurosurgeon, who would have been the one to place the Halo device. No MRI/CAT scan. What necessary precautions were in place at the hospital? Sounds like the victim, husband and their attorney practiced this “accident” manipulation. If she had significant frontal bruising on both legs below her knees, she didn’t get hit from the side as stated, but her legs hit the underside of the dash on frontal impact. Displaced Hangman’s fractures may require surgery. Possible complications could be paralysis. Risk of death always a possibility with general anesthesia. Records needed: full police report w/accident illustration, EMS records, ER records, all consults, X-rays, MRI, CAT scan, timeline from suspect DUI to time blood alcohol was drawn at hospital, ER M.D. and RN assessments, accident witness statements and statement from store owner on her demeanor when she went into the store to phone her husband, and conversation details. Prior to agreeing to take this case, I would advise the attorney to investigate Linda, her husband and attorney to see if they had other “Accident” claims or suits, and the circumstances surrounding each incident. Experts: Emergency Medicine M.D. (board certified), Nuerosurgeon, insurance fraud investigator. This sounds like a pre-staged accident that back-fired.       BEN CHAPMAN'S RESPONSE: All cases have merit, though all to different degrees, this one has more than one may initially believe. The defendants to the suit should include the tow truck driver as he was charged with the accident, the tow truck company as they are liable for the actions of their employees, the Police Officer as soon as he smelled the alcohol, he could have and should have made her go to the hospital as she may not have had the cognitive ability to make that decision for herself, also Police cannot apprehend solely on a “smell” of alcohol, it actually has no odor, the EMS person as the alcohol and the head injury would allow him to administer care without consent though the lack of action is negligent, there is a possibility that Honda could be a defendant as the thigh bruising is inconsistent with the crash as described. The other questions are too complicated for a simple mined Consumer Protection Investigator.