Appendicitis: The Difference Between Men, Women and Children

In men, appendicitis usually begins with a cramping wave-like mid-abdominal pain, that after number of hours, usually within a day, the pain is then localized in the right lower side of the abdomen.

The cramping pain is because the appendix is being blocked by a concretion, a solid mass of feces, and that cramping pain is caused by the contractions of the appendix trying to push it out.

But once the block remains, the protein mucus (germ food) in the appendix allows the bacterial germs proliferate. This causes the appendix to become inflamed from acute infection. And that infected appendix touching the inside of the abdominal cavity, its peritoneal lining’s thousands of tiny nerves, causes the localized pain.

In a woman, it is the exact same situation with appendicitis. However, making the correct diagnosis is complicated by the possibility of the infection being caused instead by pelvic inflammatory disease, usually caused by the bacterial germ gonorrhea, infecting the fallopian tubes. Here instead of a low-grade fever of approximately 100°, it’s usually between 102° to 103°. During a pelvic examination, by pushing on the mouth of the womb, the cervix, this causes severe pain. That helps distinguish between appendicitis versus infected fallopian tube‘s.

In children, the sequence of events is much faster, usually within 12 hours to one day until the rupturing of the appendix occurs. And unlike in adults, the omentum, the fat pad that hangs down from the stomach and large intestine is much less developed, and therefore infection can spread throughout the abdominal cavity, which is called peritonitis. In adults, it’s more likely that this fat pad will wall off and then localize the infection causing an abscess, rather than a widespread and potentially deadly infection, peritonitis.


Large Intestine (colon) and Rectal Cancer Negligence

Large intestine (colon) and rectal cancers are two of the most common cancers affecting men and women, and particularly as they age.

This cancer begins in the lining of the large intestine or rectum, the mucosa. If it is discovered while it is still in the lining before eroding into the muscular wall of the intestinal tract, then there is a 95 percent cure rate. But once it penetrates the muscular wall, the survival diminishes to approximately 70 percent, and if it spreads into the lymph nodes, the drainage sites where the inter-cellular fluid will be filtered, then the cure rate drops into the 30 percent range, but once it is in the liver, there is really no cure that point.

As the cancer grows, it encircles the intestinal track from within, which is referred to as an “apple core lesion.” Eventually, the cancer would block the fecal flow completely.

Before surgery it is critical that the intestinal tract be cleansed. The patient is put on a liquid diet and has laxatives. Enemas are also given. A clean intestinal tract is important because fecal matter are mostly germs, which would increase the risk of any infection.

At surgery it is important not to manipulate the cancer itself, to prevent the spread of cancer cells into the veins and lymphatic vessels (which transport the fluid from between the cells). This avoidance of handling the cancer itself is called the “no touch technique.”

When surgery is performed on the large intestine, the area involving the cancer and healthy large intestine a few inches above and below the cancer are removed (resected). Then the continuity of the intestinal tract is restored with either sutures or staples. When using the stapling device it is negligent to obstruct the passage way, the lumen, for the fecal matter to pass through.

When the cancer has caused a total blockage of the large intestine, then the cancer is removed but the upstream end of the large intestine is brought out through the abdominal wall as a colostomy. Then, after a few months, an operation then will take place by suturing the two ends together, but this occurs after the few days in which the intestinal tract is thoroughly cleaned.

More than 1/3 of rectal cancer‘s are able to be felt by the rectal examination. If the cancer is higher up, above a few inches, then it would be possible to remove the cancer and sew the large intestine back to the remaining area of the rectum.

If the cancer is too close to the anus, there is not enough healthy flesh between this cancer and the large intestine for suturing together. Therefore, the entire lower rectum is removed. This is called the of abdominal-perineal resection. The surgeon operates through the abdominal cavity to reach the cancer from above and to perform a colostomy, and at the same time the operation occurs surrounding the anus and removing the rectum with the cancer from below. Drains are inserted.

If the surgeon literally scrapes the inside of the sacrum, the lower most portion of the spine, that would sever multiple blood vessels and create a severe hemorrhage which can cause the death of the patient. There is a natural cleavage plane, layers of separation between areas of flesh, and is imperative that the surgeon not scrape the sacral bone. To do so would be negligence.

Tubal ligation with intestinal perforation-Medical Malpractice?

In order to perform a tubal ligation operation, the abdomen is distended with carbon dioxide gas through a large needle, and the patient is put in a somewhat head down position so that the intestines will move out of the pelvis.

Once the abdomen is inflated, a small incision is made wherein the trocar, a large spike-like device that is hollow, within which the laparoscope will pass, is inserted. Care is taken not to perforate the intestines, particularly if there was a lower abdominal incision in which the intestines can get stuck to the inside of that abdominal scar.

Each fallopian tube, the size of a thin pink straw which is extending like arms off of each side of the body of the pear shaped uterus, is identified. It is grass with a forceps device that is attached to the electrocautery machine, and a burn is created. In the alternative, the tube can be clipped with a metal clip that secures it’s obstruction so no egg can pass down for fertilization.

In performing this operation, it is critical that at all stages the intestines are protected. Before the electrocautery device is turned on, it is essential that the intestines are not touching the tip of the electrocautery forceps. Likewise, when the punctures or created into the abdominal cavity, care is taken to be sure there is no injury to the intestines. As soon as the laparoscope is inserted, the gynecologist must check and see that there has been no damage to the intestines which can result in a perforation, and peritonitis from leakage, which if not timely recognized, could be deadly.

Obstructed Labor, The Cause of Severe Brain Damage

Once a woman goes into labor, it usually progresses in a steady fashion. The pelvic exam can determine the head of the fetus in relationship to the inside of the bones in the birth canal, the pelvis. There is a bony landmark in the pelvis which will be used as the guide in centimeters, as to whether not the fetal head it is minus or plus centimeters as a guide to gauge the progression of the labor.  If this woman is a primigravida, that is pregnant for the first time, now and having a vaginal delivery, this is called an “untried pelvis.” And if she has a narrow pelvis, the android shape, more male-like, as opposed to the gynecoid shape of the fuller pelvis, then this is a red flag that there may be a problem with the head of the fetus passing through the birth canal.

If there is no progression of labor down the birth canal, centimeter by centimeter, then this is a problem that may require a cesarean section rather quickly. The fetal heart monitor under these circumstances is really not the better way to determine if they will be a problem. If the umbilical cord is compressed, then the oxygenated blood supply from the uterus to the fetus would be impaired and the fetal heart rate would drop dramatically. That requires it immediately Cesarean section. But in this case of the failure of progression of labor, the umbilical cord is not compressed, but the head is repetitively forced against the inside of the solid bone pelvis. Unlike football players wearing a helmet, this fetal skull has no helmet, and its head is forced under great compression pressure, every few minutes, as opposed to an occasional football concussion. This repetitive concussion will cause brain damage. The failure to observe an obstructed delivery is a departure from the accepted standard of care.

Surgical Mesh Complications in Hernia Repairs

A hernia is a weakness in the abdominal musculature, through which the intestines can protrude. For many years, since the late 1800s, surgeons have been repairing this weakness by suturing the layers of the adjacent fibrous flesh together.

However, because of the low but significant failure rate of the original suturing to hold, requiring a repeat hernia operation, which by itself is not a departure from the accepted standards of care, or when an operation was required to repair a very large hernia, surgeons have been using a plastic woven cloth, a mesh. This allows the body’s scar tissue to grow into this material, to serve as an internal girdle, a buttress, to decrease the failure of the surgical repair.

Whenever any foreign material is inserted into the human body, there is an increased risk of infection. The presence of foreign material makes it much more difficult for the body to fight off any infection. Even with the most sterile procedures, there is that very small risk of infection, including from the human body itself, such as from brushing teeth, where germs can enter the bloodstream and “seed out” at that surgical mesh site.

Furthermore, whenever any foreign material enters the human body, there is a small propensity for the body to eliminate it, as if it were a splinter working its way through the skin.

The standard of care requires that the surgeon explain the need for the use of the mesh to lower the failure rate for the hernia repair. And during this discussion, the surgeon also needs to inform the patient of the slight increased risk for infection, as well as the possibility for the foreign substance to work its way out of the body.

Thoracic Outlet Syndrome

Thoracic outlet syndrome is a condition where the nerves in the arm, the brachial plexus, are squashed between the collarbone (clavicle) and the first rib beneath. When the patient repetitively raises their arms up (as in hanging sheetrock on the ceiling) they can have numbness and nerve difficulties with their arms. That doesn’t mean an operation is indicated, however.

They can be instructed to change their job, and physical therapy can be effective. If the condition is severe it must be confirmed by doing what is called an Adson Maneuver. This involves raising your arm up in the air and all the way back to where the pulse to your wrist is cut off. The artery goes through the same area the nerves are going through and will be compressed by the squeezing action of those two bones. If this test is positive it does not necessarily mean that surgery is needed; many people can have a positive test without any symptoms.

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Urology and the Potential for Medical Malpractice

I was invited to write an article about potential medical malpractice situations in Urology. I thought about several areas of urology and what the common denominators were. The two I see most frequently are … failure to diagnose and/or treat appropriately and failure of communication in an understandable and comprehensive manner with the patient and designated second (if appropriate). I have chosen to discuss the failure to diagnose, evaluate and treat hematuria (blood in urine) in an appropriate manner.

Hematuria may occur in an isolated field (no associated symptoms) or associated with urgency, frequency, dysuria, abdominal pain. Fever is variable. Abdominal distention (swelling or bloating) is also variable. Usually, the first physician seen is the PCP who will usually institute treatment for a UTI. He should obtain a urine culture as the minimal workup along with a urinalysis. If this treatment does not work or the bleeding recurs in a short period of time, a referral to a urologist is indicated.

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The Benefits of a Physician Assistant Expert Witness

Physician Assistants have been involved in the American Health Care Systems for over forty years. The American Academy of Physician Assistants was founded in 1968 as the official body representing the profession with a mission “to provide quality cost-effective, accessible health care and to promote the profession and personal development of physician assistants”. There are more than 140 physician assistant programs in the United States. The U.S. Bureau of Labor Statistics (BLS) projected that physician assistant employment opportunities will grow 50% by 2014. This will make it the fourth fastest growing profession in the country

Physician assistants are either licensed or registered in every state in the union including Puerto Rico, Guam the District of Columbia and the Virgin Islands and have prescriptive authority in every jurisdiction. Forty‐four states allow PAs to prescribe controlled substances. PAs are required to register with the Drug Enforcement Agency and possess a valid DEA number to prescribe controlled medication.

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Prostate Cancer: Delay in Diagnosis, Failed Follow Up Strategy

Attorneys are often consulted by patients who feel that they have not been properly followed after cancer had been treated and that a recurrence could have been diagnosed earlier but was missed. Different cancers have different follow-up recommendations. For prostate cancer, PSA is the mainstay of the follow-up strategy.

One consequence of the routine adoption of PSA monitoring after treatment of early-stage prostate cancer is the identification of men with a PSA-only recurrence. In this situation, increases in serum PSA over the pretreatment baseline are often not accompanied by signs or symptoms of progressive disease. When PSA rises, the physician is often faced with a quandary. The longer one waits to perform an imaging study, the greater the chance that a recurrence can be confirmed and treatment started.

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Cancer Pain Management Negligence

Safe and effective chronic opioid therapy for chronic cancer-related pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion. Although evidence is limited in many areas related to use of opioids for chronic non-cancer pain, several guidelines provide recommendations developed by a multidisciplinary expert panel after a systematic review of the evidence.

Generally, narcotics are not the only modality that can be used to treat pain. Adjuvant therapies together with narcotics can be very helpful. For example, steroids and non-steroidal anti-inflammatory drugs, such as ibuprofen(Advil) can reduce the inflammation associated with tumors pressing on tissues, and certain anti-depressants and anti-seizure drugs can modify how the brain perceived pain and lessen it. There are also procedures, such as nerve blocks, that can be helpful when pain is localized.

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