Medicolegal Implications Research Articles

Gossypiboma: An avoidable but not a rare complication

Gossypiboma is defined as mass of cotton matrix which is left in the body after surgical procedure. It is a rare complication detected after surgical procedure. This condition is under reported because of medicolegal implications. We hereby report three cases of gossypiboma encountered in clinical practice. The preoperative diagnosis of a foreign body was made in two cases. However, in one case it was misdiagnosed as a hydatid cyst.

Síndrome compartimental agudo del miembro inferior: estado actual

El síndrome compartimental agudo del miembro inferior es una urgencia médica, que puede conllevar una importante morbilidad para el paciente y que puede tener implicaciones medicolegales para el personal médico. Afecta cerca de 3,1 por 100.000 habitantes en el mundo occidental, con predominio de hombres y jóvenes. Debido a una alteración de la perfusión tisular, por la disposición de los músculos de las extremidades en compartimientos compactos, con poca tolerancia a variaciones en la presión, puede causar isquemia, con cambios irreversibles a nivel muscular y nervioso, falla multiorgánica y la muerte, de no tratarse oportunamente.
 El trauma de la extremidad inferior asociado a fractura es la principal causa del síndrome compartimental agudo. El diagnóstico puede realizarse por evaluación clínica, mediante las clásicas seis “P” de la isquemia, u de manera objetiva, al medir la presión intracompartimental con dispositivos especializados. La fasciotomía descompresiva es un procedimiento quirúrgico mediante el cual se inciden las fascias de los compartimientos musculares, permitiendo la disminución de las presiones a ese nivel, y se constituye en el único tratamiento eficaz para el síndrome compartimental agudo. Las complicaciones posquirúrgicas no son infrecuentes, siendo la perdida de la extremidad la más grave de todas. Un correcto conocimiento y aplicación de la técnica quirúrgica evitará procedimientos inadecuados, que impliquen mayor riesgo de resultados adversos.
 Presentamos una revisión de los aspectos fundamentales de esta patología potencialmente catastrófica.

Autologous Fascial Slings for Surgical Management of Stress Urinary Incontinence: A Come Back.

Stress urinary incontinence (SUI) is a common type of urinary incontinence adversely affecting the quality of life of women. For mild SUI, life style changes, pelvic floor exercises and medical treatment with duloxetine may help. Most patients of moderate to severe SUI usually require surgical treatment. Various surgical treatment options include Kelly's plication, Burch colposuspension, bulking agents and sling surgeries. Although, suburethral fascial slings including the autologous rectus fascia slings were in vogue before 1990, they were overtaken by minimally invasive, faster and easier artificial midurethral slings (tension free vaginal tape and transobturator tape). However, observation of serious long-term and life changing complications of synthetic midurethral slings like mesh erosion, chronic pelvic pain and dyspareunia led to their adverse publicity and medico legal implications for the operating surgeons. This led US FDA (Food and Drug Administration) to issue a warning against their use. Currently, their use has significantly decreased in many countries, and they are no longer available in some countries. This has led to renaissance of use of natural autologous fascial sling, especially rectus fascia for surgical management of SUI. Although performing rectus fascia sling surgery is technically more challenging, takes longer, has more short-term morbidity like voiding dysfunction, their long-term success is high with very little risk of serious complications like mesh erosion, chronic pelvic pain and dyspareunia. However, multicentric trials and longer follow ups are needed before it's routine recommendation This review discusses the role of autologous fascial sling (especially rectus fascia) for the surgical management of SUI in the current time and the need of ongoing training of this procedure to gynecology residents and urogynecology fellows.

Intra-abdominal Breakage of Laparoscopic Needle Holder Tip and Its Retrieval Under Fluoroscopic Guidance.

Intra-operative breakage of laparoscopy instruments is a rare occurrence. It entails a risk of the foreign body being retained in the abdomen and may lead to medico-legal implications. The foreign body migrates due to bowel movements. Therefore, the retrieval of such foreign bodies can be challenging even for a highly skilled and experienced surgeon. Fluoroscopy can guide in locating the missing foreign body. The only preventive measure is the vigilance of the operating team and thorough inspection of all the instruments prior to completion of surgery. We present a case report of a 50-year-old lady who underwent total laparoscopic hysterectomy with bilateral salpingoopherectomy at a private nursing home. During the closure of the vault, the tip of the needle holder broke inside the abdomen and the primary surgeon was unable to retrieve it. The missing tip of the needle holder was removed from the right hypochondriac region, by a second laparoscopic surgery by an advanced laparoscopic surgeon under fluoroscopic guidance. Intra-operative breakage of laparoscopy instruments can occur, demanding a great deal of expertise for the retrieval of such foreign bodies. Fluoroscopy can guide in locating the missing foreign body which can be retrieved by an expert laparoscopic surgeon.

Telemedicine practice guidelines in India: Medico legal implications

Providing in-person healthcare services is challenging, especially in a vast country like India, where most of its citizens reside in the rural area. In this scenario, telemedicine can provide faster and timely healthcare services to the needy ones where distance is the critical factor. Healthcare seekers need not travel long miles for obtaining treatment and consultation. In most situation, telemedicine services are beneficial to the patients. A person staying in far remote area may access healthcare facility through telemedicine, thus avoiding issues related to mobility of the patient especially in elderly and debilitated patients. On the other side, telemedicine has its own limitation due to its virtuality. The person staying in remote area may not have access of tools required to access telemedicine facility. Internet connectivity in remote area is another issue. Telemedicine services could change face of providing medical services to the person residing at distant or in remote area if implemented effectively. Proper infrastructure is must to achieve this target. Information technology related instruments and services needs to be strengthened up at grass root level to provide better coverage of telemedicine facilities to needy ones. Telemedicine provides the safety of physicians and the patients, especially where there is a high risk of infection spread, such as in the present COVOD-19 pandemic. Mainstreaming telemedicine in the health system will improve the efficiency and outcome of the country's healthcare system.

Hospital-Acquired SARS-Cov-2 Infections in Patients: Inevitable Conditions or Medical Malpractice?

Despite numerous measures to contain the infection and limit its spread, cases of SARS-CoV-2 infections acquired in hospitals have been reported consistently. In this paper, we will address issues of hospital-acquired COVID-19 in hospitalized patients as well as medico-legal implications. After having conducted a literature search, we will report on papers on hospital-acquired SARS-CoV-2 infections. Ten scientific papers were selected and considered suitable for further analysis. According to several reports, the SARS-CoV-2 hospital-acquired infection rate is 12–15%. Hospital-acquired COVID-19 represents a serious public health issue, which is a problem that could create reluctance of patients to seek hospital treatment for fear of becoming infected. Healthcare personnel should do all that is necessary to address the problem and prevent further spreading, such as rigorous compliance with all procedures for containing the spread. From a medical-legal point of view, multiple aspects must be considered in order to understand whether the infection is a result of “malpractice” or an inevitable condition.

RETAINED SURGICAL SPONGE IN ABDOMEN – A CASE REPORT

Retained foreign body is a major complication that can occur in early or delayed postoperative period having both clinical as well as medicolegal implications. We hereby report a case of 47-year-old female with retained surgical sponge in abdominal cavity after hysterectomy. Thorough count of all sponges before and after any surgery can aid in avoiding such an undesirable event and preferable use of labelled sponges can help in early diagnosis in such cases.

Successful Endoscopic Removal of a Transmural Internally Migrating Gossypiboma

AbstractAn accidentally retained sponge inside the body of a patient (gossypiboma) is a rare and serious adverse event after a surgical procedure with serious medicolegal implications and complications. It is commonly associated with abdominal surgeries with cholecystectomy most commonly implicated. Whorl-like appearance or mottled translucencies and radiopaque marker on imaging is diagnostic. Transmural migration into a hollow viscous has been infrequently reported. The preferred approach for the removal of gossypiboma is surgery. However, in cases of complete transmural migration, endoscopic removal remains a viable option.

Legal scenarios in the coronavirus time: Medico legal implications in the aspects of governance.

Along with rising levels of the infection around the world, the state of emergency prompted by the COVID-19 pandemic has also been having a heavy legal impact. The situation is posing important criminal challenges, as well as an ocean of social and public health issues around the world. It has not only directly affected constitutionally-guaranteed rights and individual freedoms, but also brought to the fore certain types of criminal offence that had previously been of little practical importance, such as the crime of 'maliciously or unintentionally causing an epidemic'. Different countries and states have introduced policies to manage the emergency at different times and in different ways. The measures adopted have been the object of much criticism, also raising questions of constitutional legitimacy in countries like Italy. The present contribution begins with a brief outline of the different international scenarios. Then we examine some of the medicolegal aspects of criminal offences previously envisaged and newly introduced since the arrival of the pandemic. We suggest the need for a sort of 'code of public health laws for the time of coronavirus', that could also be applied to other public health emergencies, pandemic or otherwise. The idea is to give operators in the sector and the general population the opportunity to identify clear and simple rules to follow in the current complex global situation. We need a new, appropriate interpretation of the 'boundaries' of our individual rights in relation to the need to safeguard the wider community and its more vulnerable members.

A Century in Review: Medicolegal Implications of Facial Nerve Paralysis.

Importance: It is important to recognize factors that may mitigate the risk of a potential lawsuit and increase knowledge and awareness of physicians. Objective: To evaluate and characterize facial nerve paralysis litigation claims and related potential causes. Design, Setting, and Participants: These data were extracted from the two main computerized legal databases: WestLaw and LexisNexis. The data were queried on April 2, 2020. The records from 1919 to 2020 were obtained from a population-based setting. A total of 186 cases were included. Data were gathered for all alleged cases of facial nerve paralysis. Main Outcomes and Measures: There was a continuous rise in the amount of malpractice payments with the highest mean amount being in the past decade. Results: From 1919 to 2020, a total of 186 malpractice cases for facial nerve damage were identified. A total amount of $89,178,857.99 was rewarded to plaintiffs in 66 cases. The mean amount of paid malpractice claim was $1,351,194.80. Improper performance/treatment was the most common reason for alleged litigation (n = 97). This was followed by misdiagnosis/delayed diagnosis (n = 47), and failure of informed consent (n = 34). The highest number of malpractice claims with a total of 53 cases was from 1991 to 2000. The highest mean amount per payment was in the past decade (2011-2020) with a mean of $3,841,052.68. Conclusions and Relevance: Over the past century, improper performance/procedure, delayed/misdiagnosis, and failure of informed consent were the most common reasons for litigations related to facial nerve paralysis.

Trance-it to the Future

Trance-it to the Future

Autopsy study of maternal death in a tertiary care centre

Aims: The main objective is to study the gross pathology and microscopy of all organs in cases of maternal death, establish clinico-pathological correlation, to ascertain the exact cause of death and classify them into direct or indirect causes. Settings and Design: Cross sectional study of all medical autopsies. Materials and Methods: A cross sectional study of all medical autopsies performed on deaths related to pregnancy at our tertiary care hospital over a period of four years. A total of 100 cases were studied. Maternal mortality autopsies where medico legal implications were involved or unnatural deaths not related to pregnancy were excluded from the study. Statistical Analysis used: Nil Results: The maximum no. of maternal deaths occurred in the age group 20-24 years (45%) followed by 30-34 years (19%). 62% of patients in our study were multigravidae. Majority of maternal deaths were seen in the postpartum period (75%). In the antepartum period maximum number of maternal deaths occurred in 3rd trimester (14%) Our study revealed majority of maternal deaths were due to indirect causes (76%), Pregnancy induced hypertension was the most common direct cause of death (9%). The majority of cases were due to infectious aetiology (45%), while the other indirect causes were sepsis (14%), coagulopathy (8%) and hemodynamic (8%). Conclusion: The higher MMR in our study could be attributed to the fact that ours being a tertiary and referral care hospital, where patients are referred late and most of them are complicated cases and in serious condition at the time of admission. The low socioeconomic status of the patients, delay in referral and non-utilisation of the available antenatal care could be the major contributing factors. Our study revealed majority of maternal deaths were due to indirect causes especially respiratory infections and hepatitis Increased incidence of indirect causes reflect the present health care system. So adequate prenatal testing for these causes

Pseudo-subarachnoid hemorrhage: A tricky CT finding with serious medicolegal implications

Abstract Introduction Pseudo-subarachnoid hemorrhage is a radiological term used to describe increased attenuation values on computed tomography within the basal cisterns and subarachnoid spaces, simulating true subarachnoid hemorrhage. Cases We present two cases of drug users, both showing a pseudo-subarachnoid hemorrhage pattern on computed tomography after a circulatory collapse with subsequent resuscitation. After fatal outcome, both cases underwent forensic autopsy including pathology and toxicological analysis. Discussion We compared postmortem findings with antemortem imaging, and found that differentiating pseudo-subarachnoid hemorrhage from true-subarachnoid hemorrhage can be quite challenging. However, medicolegal consequences are important (i.e. diagnosing a real subarachnoid hemorrhage as a pseudo-subarachnoid hemorrhage, or vice versa) since certain diagnoses may lead to a judicial inquiry, and careless diagnosis may lead to wrongful prosecution.

A Review of osteological remains submitted for forensic examination in south Australia over a 7-year period (2013–2019)

The files of the Pathology section of F Forensic Science South Australia (FSSA) Adelaide, Australia were examined over a seven-year period from January 2013 to December 2019 for all cases where skeletal remains had been submitted for assessment. There were 150 cases comprising 79 non-human (53%), 49 traditional Australian Aboriginal (33%) and 12 Coronial (8%). The remaining cases included anatomically prepared skeletal remains or other historic remains, and four cases which were subsequently determined to be non-osseous. The large number of domestic animal bones found reflects the agricultural nature of much of the state in addition to historical urban butchering practices. The next largest category was that of indigenous remains associated with the long history of Aboriginal occupation. Established protocols ensure that this culturally-sensitive skeletal material is passed on to the appropriate traditional community leaders. This study shows the unique range of skeletal materials that is currently being forensically assessed in South Australia and the varied medicolegal implications of each category.

Gossypiboma with perforation of the umbilicus mimicking a complicated urachal cyst: a case report

BackgroundA retained surgical sponge, also known as a gossypiboma, is a rare cause of serious postoperative complications. Diverse retained surgical materials including instruments such as clamps and sutures have been reported, but surgical sponges are the most common material. We report an unusual case of a gossypiboma mimicking a complicated urachal cyst that led to perforation of the umbilicus.Case presentationA 38-year-old female patient presented in our facility with a palpable periumbilical mass and discharge of pus from the umbilicus for 7 months after an open appendectomy. Since the onset of symptoms, the patient had been treated conservatively in a peripheral hospital where she had been operated on. As no improvement was seen, an ultrasound scan was performed that suggested an intraperitoneal abscess adjacent to the umbilicus. Consequently, the patient was referred to our specialist outpatient department for surgical intervention. Suspecting a complicated urachal cyst, an exploratory laparotomy was performed but revealed a retained surgical sponge as the underlying cause. The gossypiboma was resected, and the postoperative period was unremarkable.ConclusionThis case demonstrates that gossypibomas, even though rare, continue to occur. They may clinically and radiologically mimic other pathologies, especially abscesses and tumors. Preventive measures as well as the inclusion of gossypibomas in the differential diagnosis of intraabdominal masses or fistulation detected in patients with a history of surgery are of utmost importance to minimize morbidity, mortality, and potential medicolegal implications.

A Curious Case of Gossypibioma

The term gossypibioma is used to describe a retained surgical sponge or gauze after operation. It is a rare but serious complication which is seldom reported because of the medicolegal implications. Gossypiboma usually has varied and vague presentation and is also difficult to detect on radiological investigations. It can even remain silent and present years after the operation. We report a case of a 74-year-old man who presented with chronic lump since 1 year in the right lumbar region. He had a history of spinal surgery 20 years ago.They had taken right iliac crest as a graft during that spinal surgery. Radiological investigations were inconclusive in detecting the retained gauze. A working diagnosis of soft tissue tumour-? Desmoid tumour was made on ultrasonography and an excision of lump was done where he was found to have a large gossypibioma densely adhered to the right iliac crest. Though rare, gossypibioma should be kept in mind as a differential diagnosis in postoperative cases presenting as vague pain or chronic lump even years after the operation.

Strategies of Avoiding Medicolegal Problems

“Medicine is of all the arts the most noble, but owing to ignorance of those who practice it, and those who, inconsiderately form a judgment of them, it is at present far behind all other arts.” Hippocrates The provision of unnecessary health care is a serious problem and involves two key legal issues. First, doctors’ fear of litigation drives defensive practices – ordering tests and procedures, making referrals, and prescribing drugs to reduce perceived legal risks, rather than to advance patient care. Second, suboptimal communication and decision-making processes undermine a patient’s right to make informed health-care choices [1]. Information is available to judge and evaluate with limited knowledge in the field. Do we feel the same thing nowadays? Probably yes; and before consulting a patient, medicolegal implications are the first fear in our mind due to some of the facts such as decline in self-regulatory standards, rise in medical malpractices and commercialization, imbalance between service and business, and lack of an effective internal or external regulation. We must not forget the truth that there is a public outcry against medical profession due to some incidences, which is generally being applied to all healthcare professional community by media because of negative coverage. We should also remember that this is not the commonest issue in each doctor’s career; and media are not always negative, however, only a few incidences will imprint a general impression on the mindset of public and end up in to medicolegal consequences. We must come out of this fear and phobia and succeed in career if we maintain an acceptable standard of care and communication. If we discuss about the difference of medicolegal problems between physicians and surgeons, it is found that surgeons receive complaints twice as much as received by physicians [2]. This increased risk of litigation arises partly from involvement in surgical procedures and treatments but also reflects wider

Unusual presentation of metastatic malignant melanoma: a case report

Introduction: The presentation of metastatic lesion of malignant melanoma (MM) may be unusual, as this case, in which the lesions were multicystic swelling over right arm and necrotized swelling at right chest wall. Identifying the unusual variants of MM is important to allow application of the most appropriate treatment strategies before something wrong happens. Methods: This case report has been prepared following the SCARE guideline 2018, a surgical case report guidelines. Presentation of the case: A 60-year-old man presented with a 14-month history of swelling on right arm and anterior chest wall with the chief complain of blackish discharge from the latter. Six months ago, he amputated his right thumb for melanoma after a histopathology evaluation. It was an unusual presentation of a metastatic lesion of MM. On the basis of the histopathology report, the final diagnosis of our patient was subcuticular metastatic MM which has a very poor prognosis. According to TNM classification, the final diagnosis of the case was T4bN0M1a. Although he has been under regular follow-up, the lesions are still present and his health condition is deteriorating. Discussion: Metastatic melanomas are often rare; their misdiagnosis potentially jeopardizes patients’ health and survival, and have medico-legal implications. Melanoma often has a protracted disease course, in which patients have a disease-free period following surgical excision of the primary tumor, only to discover visceral metastases—months, years, or even decades later. Melanoma metastasis is an ominous sign as it generally predicts a poor prognosis. This case is an unusual presentation of metastatic melanoma where, with the elaboration of history and proper examination of lesion, the diagnosis of metastatic melanoma was made. Conclusion: Metastatic MM has a very poor prognosis and an early diagnosis with clinical presentation is very essential in a country where health facilities are not well developed. Knowing the unusual variants of MM is important to allow application of the most appropriate treatment strategies before something wrong happens.

Risk Management in the New Frontier of Professional Liability for Nosocomial Infection: Review of the Literature on Mycobacterium Chimaera.

Background: Mycobacterium chimaera (MC) is of recent origin and belongs to the large family of non-tuberculous mycobacteria. In recent years, it has shown a high infectious capacity via the aerosol produced by operating room equipment, such as heater–cooler units (HCU). The infection has a long latent period and high mortality rate. Genetic and epidemiological studies have shown that there is a clear link between the infection and a specific HCU model manufactured by LivaNova/Sorin. There is, therefore, a strong possibility that contamination occurs during device construction. The objective of this article is to describe the characteristics of this particular infection in view of the medico–legal implications on professional liability, specifically focusing on current evidence regarding contamination prevention. Methods: we have analyzed the clinical characteristics and data from the autopsic investigations performed on a patient who died as a result of MC infection, in addition to analyzing all pertinent recommendation documents available internationally. We searched for all articles in the literature available on MEDLINE between 1995 and 30 July 2020, using the search words “Mycobacterium chimaera”. We then analyzed those articles and reported only those that provide useful information regarding prevention techniques for containing dissemination and contamination. Results: the literature review produced 169 results that highlight the need to develop systems to mitigate and eliminate the risk of MC infection in operating rooms such as physical containment measures, e.g. device replacement, use of safe water, providing patients with information, and training healthcare professionals. Conclusions: from a medico–legal viewpoint, this particular situation represents a new frontier of professional liability, which includes manufacturers of electromedical equipment. In order to comprehend the true extent of this silent global epidemic, the development of an organic, preventative monitoring system is essential.

Testicular Torsion in the Emergency Room: A Review of Detection and Management Strategies.

Testicular torsion is a challenging and time-sensitive diagnosis that is encountered frequently in daily practice, especially in the emergency room. A thorough history, the presence of a painful and swollen testis and testicular ultrasonography plays a vital role in the prompt diagnosis of testicular torsion. Prompt diagnosis is essential to prevent complications of testicular torsion which include testicular infarction, necrosis, and sub/infertility. This can be challenging as there are various other conditions that may mimic the presentation of testicular torsion. Since testicular torsion is an extremely time-sensitive diagnosis, it may also be a subject of many medicolegal challenges. This review article serves as a guide for clinicians involved with the diagnosis and management of testicular torsion. We review and discuss detection and management strategies based on their validity, statistical significance, and effectiveness in enabling prompt diagnosis and management of testicular torsion. Medicolegal implications of testicular torsion are also highlighted.