traumatic brain injury: navigating litigation and...

Traumatic Brain Injury: Navigating Litigation and Settlement Complexities Assessing Claims, Negotiating Settlements, and Leveraging Witnesses

Today’s faculty features:

1pm Eastern | 12pm Central | 11am Mountain | 10am Pacific

The audio portion of the conference may be accessed via the telephone or by using your computer's speakers. Please refer to the instructions emailed to registrants for additional information. If you have any questions, please contact Customer Service at 1-800-926-7926 ext. 10.

WEDNESDAY, OCTOBER 30, 2013

Presenting a live 90-minute webinar with interactive Q&A

Dr. Matthew J. DeGaetano, Program Director and Founder, Personal Injury Institute, Dallas

Randall L. Rozek, Founder, Rozek Law Offices, Milwaukee

John Jerry Glas, Partner, Deutsch Kerrigan & Stiles, New Orleans

Dr. Glenn T. Goodwin, DABFE, Consulting Neuropsychologist, Edmonds, Wash.

Tips for Optimal Quality

Sound Quality If you are listening via your computer speakers, please note that the quality of your sound will vary depending on the speed and quality of your internet connection. If the sound quality is not satisfactory, you may listen via the phone: dial 1-866-869-6667 and enter your PIN when prompted. Otherwise, please send us a chat or e-mail [email protected] immediately so we can address the problem. If you dialed in and have any difficulties during the call, press *0 for assistance. Viewing Quality To maximize your screen, press the F11 key on your keyboard. To exit full screen, press the F11 key again.

FOR LIVE EVENT ONLY

Continuing Education Credits

For CLE purposes, please let us know how many people are listening at your location by completing each of the following steps:

• In the chat box, type (1) your company name and (2) the number of attendees at your location

• Click the SEND button beside the box

If you have purchased Strafford CLE processing services, you must confirm your participation by completing and submitting an Official Record of Attendance (CLE Form).

You may obtain your CLE form by going to the program page and selecting the appropriate form in the PROGRAM MATERIALS box at the top right corner.

If you'd like to purchase CLE credit processing, it is available for a fee. For additional information about CLE credit processing, go to our website or call us at 1-800-926-7926 ext. 35.

FOR LIVE EVENT ONLY

Program Materials

If you have not printed the conference materials for this program, please complete the following steps:

• Click on the ^ symbol next to “Conference Materials” in the middle of the left-hand column on your screen.

• Click on the tab labeled “Handouts” that appears, and there you will see a PDF of the slides for today's program.

• Double click on the PDF and a separate page will open.

• Print the slides by clicking on the printer icon.

FOR LIVE EVENT ONLY

Dr. Matthew J. DeGaetano [email protected]

800-794-7896

MILD TRAUMATIC BRAIN INJURIES “MTBI”

Post Concussion Syndrome Closed Head Trauma Soft Head Injury Blunt Head Injury Post-Head-Trauma Syndrome

6

Mechanism of Injury Angular Acceleration The mechanism of the trauma was previously thought to be a

shearing of axons which result from abrupt acceleration and deceleration of brain tissue (784). During a low speed whiplash injury (7 mph) the head may be accelerated to 9-18 g (87).

Since the brain is a soft structure, shear strains are created as the

outer part of the brain moves at a different pace than the inner part of the brain. This is intensified as the momentum of the head changes rapidly in a sagittal direction during a whiplash trauma.

(784) Ommaya AK, Gennarelli TA: Cerebral concussion and traumatic unconsciousness. Brain

97:6330654, 1974 (87) West DH, Gough JP, Harper TK: Low speed collision testing using human subjects. Accid

Reconstr J 5(3):22-26, 1993. (116) Ommaya AK, Hirsch AE: Tolerances for cerebral concussion from head impact and whiplash in

primates. J Biomechanics 4:13-21, 1971.

7

Mechanism of Injury 8

retroyou.org

1 g = 9.81 m/s2 it is the acceleration force induced gravitational of the at sea level

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&docid=oBMu7wFadL76GM&tbnid=lwSXEA13pyqrSM:&ved=0CAQQjB0&url=http://retroyou.org/org/retroyou/www/nostalg/des/illusions_in_flight.htm&ei=MHVVUrKKOYiO2wWGjID4Cw&bvm=bv.53760139,d.b2I&psig=AFQjCNHOxIFlaGPQ2SGky4BRhNcO1LK_2w&ust=1381418644180269

Mechanism of Injury

• Ommaya and Hirsch (116) studied the tolerances of primates to whiplash and calculated, by interpolation, that angular accelerations of 1800 rad/sec2 would result in a cerebral concussion in man about 50% of the time. They noted, however, that this threshold may very well be as low as 1600 rad/sec2.

• As an interesting note, recent crash studies have

produced angular accelerations of volunteers' heads of up to 1000 rad/sec2 in one study (1148) to as high as 1260 rad/sec2 in another (1175).

9


www.sciencedirect.com

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&docid=JnFo4sGSqRAnEM&tbnid=RoBuOHotJoN1FM:&ved=0CAQQjB0&url=http://www.sciencedirect.com/science/article/pii/S0021929004005731&ei=WnNVUo3wKoKr2wWtvIGgBg&bvm=bv.53760139,d.b2I&psig=AFQjCNG--fzh1Fx_x0mHNHb-VgQGkMxlbg&ust=1381417828445216


www.nature.com

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&docid=JnFo4sGSqRAnEM&tbnid=RoBuOHotJoN1FM:&ved=0CAQQjB0&url=http://www.nature.com/nrneurol/journal/v9/n4/fig_tab/nrneurol.2013.33_F1.html&ei=H3NVUprUPMbb2QXz3YHABg&bvm=bv.53760139,d.b2I&psig=AFQjCNG--fzh1Fx_x0mHNHb-VgQGkMxlbg&ust=1381417828445216


www.frontiersin.org

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&docid=opAleipjZR3JlM&tbnid=cR3KAiqVHzePvM:&ved=0CAQQjB0&url=http://www.frontiersin.org/Neurotrauma/10.3389/fneur.2013.00059/full&ei=uHJVUs3yGoPZ2AXl3oC4AQ&bvm=bv.53760139,d.b2I&psig=AFQjCNG--fzh1Fx_x0mHNHb-VgQGkMxlbg&ust=1381417828445216

MILD TRAUMATIC BRAIN INJURIES “MTBI”

“TBI” Traumatic Brain Injuries NOT MILD!

13

Concussion

• A concussion is a type of traumatic brain injury, or TBI, caused by a bump, blow, or jolt to the head that can change the way your brain normally works. Concussions can also occur from a fall or a blow to the body that causes the head and brain to move quickly back and forth.

• Health care professionals may describe a concussion as a “mild” brain injury because concussions are usually not life-threatening. Even so, their effects can be serious.

14

http://www.cdc.gov/TraumaticBrainInjury/index.html

Low Speed Crashes

• The most important factors in whiplash-induced concussion are angular acceleration, flexion/extension tensions in the neck, and intracranial pressure gradients.

Ommaya AK, Hirsch AE, Martinez JL: The role of whiplash in cerebral concussion. 660804 197-203, 1966.

15

Head injury Head injury can be either closed or open (penetrating).

• An open, or penetrating, head injury means you were hit with an object that broke the skull and entered the brain. This usually happens when you move at high speed, such as going through the windshield during a car accident. It can also happen from a gunshot to the head.

16

Head injury

Head injuries include: • Concussion, the most common type of traumatic brain

injury, in which the brain is shaken or the gradient sheer strains have occurred.

• Scalp wounds • Skull fractures • Head injuries may cause bleeding: • In the brain tissue • In the layers that surround the brain (subarachnoid

hemorrhage and subdural hematoma )

17

http://www.nlm.nih.gov/medlineplus/ency/article/000799.htm




Symptoms: Headaches Dizziness Memory Loss Inability To Concentrate Sleep Disorders Irritability Lightheadedness Vertigo Neck Pain Photophobia Tinnitus Easy Distractibility

18

Impaired Comprehension Forgetfulness Impaired Logical Thought Difficulty With New Or Abstract Concepts Easily Fatigued Apathy Outbursts Of Anger Mood Swings Depression Loss Of Libido Personality Changes Intolerance To Alcohol

PCS / MTBI Symptom Check List

Every firm should have their own PCS / MTBI check list. Headaches, dizziness, memory loss, inability to concentrate, sleep disorders, irritability, lightheadedness, vertigo, neck pain, photophobia, tinnitus, easy distractibility, impaired comprehension, forgetfulness, impaired logical thought, difficulty with new or abstract concepts, easily fatigued, apathy, outbursts of anger, mood swings, depression, loss of libido, personality changes and intolerance to alcohol.

19

Physical Symptoms • Dizziness • Periods of “blacking out” or seizures • Problems with coordination of hands, feet, or legs (drop things more often, balance problems) • Stuttering or slurring • Change in senses of smell or taste • Blurry or double vision • Ringing in the ears • Fatigue • More sensitive to bright light and/or loud noises • Tingling or numbness in legs and arms

20

Emotional Symptoms • Feeling of sadness and depression

• Crying spells or weepiness

• Suicidal thoughts or intentions

• Decreased or increased emotion

• Low motivation

• Decreased of increased sex drive

• Decreased or increased appetite

• Decreased interest in “fun” activities

• Difficulties with sleeping (getting asleep or staying asleep)

• Irritability / easily frustrated

• Feeling of anxiety or fear

21

Aggressive Behavior After Head Injury “TBI may go undiagnosed for months or years.

Frequency of Aggressive Behavior in the acute stage ranges from 11% to 96% in TBI.

Patients with aggressive behavior were more likely to have injuries to the frontal lobe.

Non-aggressive patients were more likely to have diffuse brain injuries.”

“Clinical Correlates of Aggressive Behavior After TBI”, Tateno et al, Journal of Neuropsychiatry and Clinical Neurosciences, 2003;15:155-160

22

Traumatic Brain Injuries - TBI • Passengers rear ended at 10 mph have a 50% chance

of sustaining a cerebral concussion. • Lateral whiplash causes the greatest TBI. • Loss of consciousness is not a prerequisite for a

concussion. • Head trauma history could indicate a skull fracture -

CT / MRI.

23

TBI should resolve in 6 months –

If not – it is probably permanent!

24

Traumatic Brain Injuries - TBI

Primary Portal of Entry for Many PI Cases

• The ER is frequently the 1st Doctor a patient will see following a MVA.

• The MD, PCP, GP is also the Doctor many patients

see after months of symptoms without relief.

• The DC are also frequently the 1st Doctor a patient will see following a MVA.

• Therefore, all providers must understand acute and

chronic Traumatic Brain Injuries!

25

In The Clinic • Pupils dilated • Spell WORLD backwards. • Count backwards from 100 by 7’s. • Remember 3 out of 5 random words 30 minutes later. • Name, address, friends, telephone numbers.

26

Traumatic Brain Injury & Serum S-100 S-100 is a protein that is created after nerve cells in the brain after injury.

90% with cranial injury had elevated S-100 protein serum levels.

Ingebrigtsen et al., “The clinical value of serum-100 protein measurements in minor head injury”, a Scandinavian multicenter study. Brain Injury 2000,14(12):1047-1055

27

Diffuse Axonal Injury

• The acceleration / deceleration causes a shearing of axons known as Diffuse Axonal Injury.

• Swelling and then regression (atrophy) of the axons. • Possible hematomas.

28

Testing: • C T scan • MRI (wait 3 months) • EEG • PET - positron emission tomography • SPECT - single-photon emission CT • BAER - brain stem auditory evoked responses • Brain Mapping • PSASAT - paced auditory serial addition test

29

MRS New Study Confirms Brain Changes From Single Mild

TBI

30

www.mildtraumaticbrainInjury.info www.PersonalInjuryInstitute.com

[email protected] 800-794-7896

• Fill out web form to receive • Free Check list PCS / MTBI • Free firm case practice audit • Law firm training platform 31

The Plaintiff Attorney’s Perspective

TBI CLIENT INTAKE

Randy Rozek Rozek Law Offices

407 W. Silver Spring Drive Milwaukee, WI 53217

[email protected]

SYMPTOM CHECKLIST

33

CDC Toolkit “Heads Up: Brain Injury in Your

Practice”

www.cdc.gov/Concussion 34

may or may not involve a loss of consciousness

(LOC) 37

Loss of Consciousness is Not Required

Page 6:

38

Post-Traumatic Amnesia is Better Predictor of Outcome after MTBI than

Loss of Consciousness

CDC Toolkit, “Heads Up: Brain Injury in Your Practice,” Acute Concussion Evaluation (ACE), Instructions, p. 2

Recent research has indicated that amnesia may be up to 4-10

times more predictive of symptoms and cognitive deficits

following concussion than is LOC (less than 1 minute).

42

Loss of Consciousness is Not Required

Page 2:

Page 6:

43

Emergency rooms miss MTBI 56% of time. Powell JM, Ferraro JV, Dikmen SS, Temkin NR, Bell KR, Accuracy of mild traumatic brain injury diagnosis. Arch Phys Med Rehabil. 2008 Aug;89(8):1550-5

45

Graham, Gennarelli, GREENFIELD'S

NEUROPATHOLOGY, 1996, p. 197

Brain Injury is a Process NOT an

Event

47

Complex Cascade of Ionic, Metabolic and Physiologic Events

Page 3:

48

A Legal Odyssey: Evaluating “Risk” In Brain Injury Cases

Presented By: John Jerry Glas

Deutsch, Kerrigan & Stiles, L.L.P. New Orleans, Louisiana

[email protected]

• Diagnostic Images

Defense Evaluation 50

Effect

Injury

51

http://www.ltscotland.org.uk/5to14/resources/illustrations/emotions/smilingbw.asp

Severity Of Injury

Brain Herniation

Midline Shift

Mass Effect

Edema

Hematoma

52

Classifications 53

Hey Rocky, did you get any brain damage? Yo, I don’t see any.

Reporter:

Rocky:

54

Trial # 1: Hairline Fracture

Trial # 2: Comminuted

& Depressed Fracture

55

Midline Shift No Midline Shift




56




Mass Effect No Mass Effect

57




Hematoma Hematomas

58


• Glasgow Coma Scale Scores


Initial Symptoms

• LOC • GCS < 15 • Seizures • Vomiting • Dizziness • Anger • Impulsivity • Headaches

• Loss of Appetite • Insomnia • Aphasia • Slurred Speech • Drainage of bloody or

clear fluid through ears or nose

• Weakness in limbs

Initial Symptoms 61

Predictors Of Outcome

“Within all domains, injury severity (as measured by 24 h GCS), pre-injury adaptive abilities (VABS), and SES were significant predictors of 30 month outcomes. . .”

62

Glasgow coma scale (Adult)

(E) Eye Opening (V) Verbal Response (M) Motor Response

4 = Spontaneous

3 = To Voice

2 = To Pain

1 = None

5 = Normal Conversation 4 = Disoriented Conversation 3 = Words, But Not Coherent

6 = Normal 5 = Localizes To Pain 4 = Withdraws To Pain 3 = Decorticate Posture 2 = No Words,

Only Sounds 1 = None

2 = Decerebrate

1 = None

63

Glasgow coma scale (Children)

(E) Eye Opening (V) Verbal Response (M) Motor Response

4 = Spontaneous

3 = To Voice

2 = To Pain

1 = None

5 = Coos, Babbles

4 = Irritable Cry

3 = Cries To Pain

6 = Normal 5 = Withdraws To Touch 4 = Withdraws To Pain 3 = Abnormal Flexion

2 = Moans To Pain

1 = None 2 = Abnormal Extension 1 = None

64

Severity of Injury

Length of Time of LOC: Mild: 0 to 30 minutes Moderate: 30 min to 24 hours Severe: 24 hours or more

66


For adults, cognitive deficits and symptoms are common in the acute stage, and the majority of studies report recovery for most within 3-12 months.

Prognosis for Mild Traumatic Brain Injury: Results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury.

Carroll, L. J., Cassidy, J.D., et al. Journal of Rehabilitation Medicine 2004; suppl. 43: 84-105

67


Cumulative Percent of Head-Injured Subjects Who Returned to Work: % Returned to Work Characteristics N 1 mo 6 mo 12 mo 24 mo GCS < 8 GCS 93 0% 13% 26% 37% 9-12 GCS 56 4% 44% 56% 64% 13-15 GCS 213 25% 63% 80% 83%

68


Prognosis for Mild Traumatic Brain Injury: Results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury.

Carroll, L. J., Cassidy, J.D., et al. Journal of Rehabilitation Medicine 2004; suppl. 43: 84-105

Where symptoms persist, compensation/litigation is a factor, but there is little consistent evidence for other predictors.

69



• Neurospychological Testing


• Impaired Function

• Area of Brain Associated w/ Function

• All Tests That Evaluate That Function

• Details About Tests & Answers

• Applicability of Practice Effect

• Daily Activities Associated With Function

• Other Functions Associated w/ Area of Brain

Deposing Neuropsychologists 71

1300 A.D. Jan. 29, 2007

Brain Cartography 73

http://www.kfki.hu/~arthp/art/zgothic/miniatur/1301-350/05e_1301.jpg

Lobes & Lymbic System 74

Practice Effect Testimony

“Based on the research – and actually one of the abstracts that Dr. Bell referred to, the research shows that people with damaged brains don’t benefit from being tested over again, and people who are normal do benefit from being tested again.”

Defense Neuropsychologist Trial Testimony

79

Memory

Language

Initiation

Judgment

Impulse Control

Social & Sexual Behavior

Motor Function

Problem Solving

Frontal Lobe Functions 82




• Pre-Morbid Ability


“Under Goodell’s new policy, all players will be required to take a baseline neuropsychological test – determining cognitive abilities, memory and motor skills – by the start of the 2007 season. That way, when a player has a concussion, he can be tested to determine what neurological changes have taken place.”

Dave Goldberg AP Football Writer May 2, 2007 Reprinted in TP-SI

84

Before After

• Pre-Accident Testing • School Records • Standardized Tests • IQ Tests • Interests & Hobbies • Employment

• Post-Accident Testing • Regression Equations • Clinical Interviews

Pre-Morbid Ability 85

“On the Wide Range Achievement Test-3, he obtained a standard score Of 88 on Reading, 64 on Spelling, and 65 on Math. These scores are Significantly lower than expected from his academic history.” Neuropsychologist’s Report

Example Case # 1 86

Pre-Morbid Writing Sample # 1 87

• Afored (afford) • Atend (attend) • Canadate (candidate) • Canidate (candidate) • Cailber (caliber) • Canot (cannot) • Comment (commitment) • Dose (does) • Extermaly (extremely)

• Finialy (finally) • Totaly (totally) • Tought (taught) • Unacepable (unacceptable) • Voluteer (volunteer) • Weather (whether)

Pre-Morbid Writing Sample # 1 88

• Alabamer (State) • Bevery Hills (City) • Brocker (Job) • Buisenn (Business) • Jennafer (Wife) • Jenafer (Wife) • Luthran (Religion) • Political Scienece (Degree) • Politicail Scince (Degree)

Pre-Morbid Job Applications 89

Pre-Morbid Admissions Letter 90

As a person with dyslexia, I have never allowed my handicap to get in the way of my goals. . .

91





• Malingering






• Malingering

• Moaners & Groaners


Scrutiny After TBI 94

• Learn All Of Their Opinions

• Learn Stories Behind Each Opinion

• Dissect Anecdotal Stories

• Find Antidotal Stories

• Define Period Of Observation

• Determine Bias Of The Observer

Anecdotal Story 95

“Normally, he’s good with kids. He has his Grandkids over and one of them spent the night, and he was short tempered. . .” Plaintiff’s Sister

Anecdotal Story 96

• Granddaughter dropped off at noon • Promised to return that night • Did not return for 24 hours • Granddaughter was 6 months old • Wife worked 7:00 a.m. to 3:00 p.m. • Plaintiff “never lost his temper”

Anecdotal Story 97

• Granddaughter dropped off at noon • Promised to return that night • Did not return for 24 hours • Granddaughter was 6 months old • Wife worked 7:00 a.m. to 3:00 p.m. • Plaintiff “never lost his temper”

Anecdotal Story 98

A Legal Odyssey: Evaluating “Risk” In Brain Injury Cases



[email protected]

NEUROPSYCHOLOGICAL CONSULTATION IN TRAUMATIC BRAIN INJURY CASES

Glenn T. Goodwin, PhD, DABFE gtgphd.com

What you end up believing depends on what you hear and who you hear it from.

101

Traumatic Brain Injury (TBI)

A spectrum of injury events along a continuum Mild concussive syndromes Mild TBI

Prolonged or irreversible coma Severe TBI

gtgphd.com

102

Chronological Process of Evaluation and Treatment of TBI and Injury related Issues

• Emergency Room Evaluation • Hospitalization, acute care and rehabilitation • General Practitioner (postconcussive syndrome) • Orthopedic Consultation (postconcussive syndrome) • Chiropractic, Massage (postconcussive syndrome) • Physical Therapy • Neurological Consultation (postconcussive syndrome)

• Neuropsychological Consultation

gtgphd.com

103

Optimum Clinical and Medicolegal Scenario It is crucial to have the network of treating providers be on the same

clinical and research awareness page with their background, training, clinical experience and understanding about TBI. Experts can be integrated into this process…directly or indirectly. Develop a solid medical foundation for the brain injury event through

convergence of evidence memorialized in medical records and then with an experienced neurologist and/or physiatrist familiar with the current research and in active practice evaluating and treating patients with mild to severe TBI. (1) An initial neuropsychological consultation to provide an

operational diagnostic assessment and clinical blueprint for refining the direction of further care and treatment…an objective evaluation of the effects of this injury event and all the injury related issues. (2) Obtain a final neuropsychological consultation down the road to make more precise estimates regarding the long-term prognosis. Obtain final assessments from the cognitive rehab providers (speech

pathologists, occupational therapists, psychologists), vocational experts and life-care planners.

104

gtgphd.com

The Task for the Consulting Neuropsychologist The starting position should be one of “clinical neutrality” An opportunity to review and examine the injury issues within the context of all available background information To determine the probability of specific factors that may be contributing to the persistence of residual symptomatology Evaluating and bringing probable explanations to the surface and highlighting these issues

gtgphd.com

105

Neuropsychological Issues in Medicolegal Cases of TBI Clinical Issues

1. Chronic pain, sleep disturbance, medication effects 2. PTSD, anxiety, depression, adjustment disorder 3. Postconcussive syndrome (PCS) 4. Somatization 5. Premorbid vulnerability

gtgphd.com

106

Neuropsychological Issues in Medicolegal Cases of TBI

Medicolegal Issues 1. Effects of litigation 2. Secondary Gain 3. Conviction of Disability/Exaggeration 4. Malingering

gtgphd.com

107

Clinical vs. Forensic Neuropsychological Consultation Clinical

• Patient is the client • Focus on diagnostics

and treatment planning • Informed consent • Greater confidentiality • Usually discoverable as

medical records • Reimbursable under

insurance provisions

Forensic • Retained expert • Referral source is the

client • Focus is on case

analysis and expert opinion

• Does not require informed consent

• Limited Confidentiality • Can be non-discoverable • Greater accountability

Shared elements: diagnostic interview and testing gtgphd.com

108

GUIDELINES FOR OPTIMUM MEDICOLEGAL PRACTICE

gtgphd.com

109

Subjective complaints alone are not a reliable or valid basis for assessing postconcussive symptoms and aftereffects of TBI.

gtgphd.com

110

Neuropsychological examination provides objective analysis and documentation of neuropsychological symptoms of TBI, other injury related sequalae and non-injury related factors.

gtgphd.com

111

Pre-existing conditions and vulnerabilities are almost always factors that should be identified and considered in explaining current functioning after accident or injury

gtgphd.com

112

Neuropsychological examination is standard practice in helping to verify legitimate residual neuropsychological symptoms of TBI and other injury related factors. Initial neuropsychological examination…documenting the injury related issues, establishing the initial post injury baseline, providing a diagnostic blueprint for care and treatment Pre-settlement follow-up neuropsychological examination…determining the final prognosis

gtgphd.com

113

GLENN T. GOODWIN, PHD, DABFE HERITAGE BUILDING 555 DAYTON, SUITE E EDMONDS, WA 98020 206-663-0816 [email protected]

gtgphd.com

The Plaintiff Attorney’s Perspective

THE TRIAL OF A TBI CASE

Attorney Randy Rozek Milwaukee, WI

Normal Imaging = No Mild Traumatic

Brain Injury

MYTH

116

ADVANCED NEUROIMAGING TECHNIQUES - DTI

119

• IMPAIRED SPONTANEITY

• IMPAIRED CREATIVITY

• IMPAIRED CONCENTRATION

• LOSS OF INIHIBITION

• EMOTIONAL LABILITY

• INCREASED DISTRACTABILITY

• FATIGUE

FRONTAL LOBE SYMPTOMS

120

PLAINTIFF FAILED TO GIVE FULL EFFORT

Neuropsychological Tests are Not Designed to Determine WHY Someone Exhibited

Poor Effort

121

Mild Traumatic Brain Injury

Symptoms Always Resolve Over Time

MYTH

122

Ronald M. Ruff, et al., Brain Injury (1996) Aug;10(8):551-65.

“Miserable minority:

emotional risk factors that influence the outcome of a mild

traumatic brain injury.”

123

RISK FACTORS FOR A PROTRACTED RECOVERY

Page 8-9: 1. Prior History of

Concussion or TBI 2. Headache History 3. Developmental

History – ADHD 4. Prior Psychological

History

125

“Patients with TBI, particular when this involves a relatively minor head injury and/or orbital frontal damage, may appear normal, claim to be normal, and perform well on tests. Nevertheless, they suffer a potentially devastating syndrome involving a constellation of disabilities, which are, in large part, consistent from patient to patient. These symptoms include mental inertia, indecisiveness, an inability to plan or anticipate, and a marked inclination to make errors of omission.”

Nils J. Varney and Richard J. Roberts, The Evaluation and Treatment of Mild Traumatic Brain Injury, Published by Lawrence Erlbaum

Associates (1999), “Posttraumatic Anosmia and Orbital Frontal Injury,” by Nils Varney, p. 127

126

• Treating Physiatrist, PCP or Neurologist

• Treating or Forensic Neuropsychologist

• Advanced Imaging Expert

• NeuroRadiologist

• Neurobehavioral Expert with Advanced

Imaging Expertise

• Life Care Planner

• Vocational Rehabilitation Expert

• Economist

PLAINTIFF’S EXPERTS

127

LAY WITNESSES

128

Bracing For The Siren Song: Trying A Brain Injury Jury Trial


[email protected]


• Separate Evidence & Testimony

Defense Trial

131

Injury

Impairment

132

Injury (Neurosurgeon/ Neurologist)

Impairment (Neuropsychologist)

C A U S E D

133

Frontal Lobe Injury (Neurosurgeon/ Neurologist)

Impaired Memory (Neuropsychologist)

C A U S E D

134


135


P R O V E S

Must have been a Frontal Lobe Injury!

136

Impaired Auditory Memory (Neuropsychologist)

P R O V E S

C A U S E D

Must have been a Frontal Lobe Injury, which must have caused the Impairment!

137

Impairment (Neuropsychologist)

Injury

138

“[The neuropsychologist] was limited by the trial court to the extent that she was allowed to testify regarding the existence of a brain injury because she is not a medical Doctor. She did testify that it was possible for a patient to demonstrate neuropsychological deficits with negative CAT scans, EMGs, MRIs, and ENGs as plaintiff did. She explained that this occurs when the brain injury is caused by nerve shearing which does not show up photographically but does show up behaviorally. Contradicting Dr. Culver, She further testified that loss of consciousness results from an injury to the brain stem but plaintiff may have injured some other part of the brain.” - Bernard v. Lott, 666 So.2d 702, 704-705 (La. 4 Cir. 12/28/1995)

Limit Neuropsychologists 140


• Identify “Missing” Injuries

Defense Trial

141

The Skull Hits First

142

COUP INJURY

Then The Brain Hits, Causing The Coup Injury.

143

The Skull Hits First

COUP INJURY

144

CONTRA-COUP INJURY

There Is Movement Away From The Opposite

145

The Brain Hits, Causing The Coup Injury.

COUP INJURY

CONCRETE

146

There Is Movement Away From The Opposite,

COUP INJURY

CONCRETE

147

COUP INJURY

CONCRETE

There Is Movement Away From The Opposite,

148

COUP INJURY

CONCRETE

CONTRA-COUP INJURY

Causing The Contra-Coup Injury.

149

CONCRETE

CONTRA-COUP INJURY

COUP INJURY

150



• Establish Strengths

Defense Trial

151

Cognitive Strengths (Average Range Or Higher)

Case # 1

• Mental Arithmetic Skills • Auditory Attention/Working Memory • Expressive Vocabulary • Delayed Nonverbal Memory • Right Hand Motor Speed • Nonverbal Intelligence • Spatial Planning • Perception of Visual Details • Visual-Construction Skills • Nonverbal Reasoning • Social Conventions & Judgment

152

Cognitive Strengths (“Not A Concern”)

• Nonverbal Intelligence • Fluid Reasoning • Visual-Perceptual

Reasoning • Processing Speed • Visual Scanning • Perceptual-Motor Speed • Single-Word Receptive

Language • Single-Word Expressive

Language • Naming of Body Parts • Comprehension of Oral

• Visual-Spatial Skills • Graphomotor construction • Reproduction of Block

Designs • Visuomotor Precision • Initial Learning • Recall of Verbal Information • Short-term Free Recall • Long-term Free Recall • Visual Memory • Basic Categorical &

Conceptual Knowledge

Case # 2 153




• Identify Unaffected Functions For “Damaged” Lobe

Defense Trial

154

Cognitive Strengths Associated With Frontal Lobe

• Mental Arithmetic Skills • Auditory Attention/Working Memory • Expressive Vocabulary • Delayed Nonverbal Memory • Right Hand Motor Speed • Nonverbal Intelligence • Spatial Planning • Perception of Visual Details • Visual-Construction Skills • Nonverbal Reasoning • Social Conventions & Judgment

Case # 1 155

Cognitive Strengths Associated With Frontal Lobe

• Nonverbal Intelligence • Fluid Reasoning • Visual-Perceptual

Reasoning • Processing Speed • Visual Scanning • Perceptual-Motor Speed • Single-Word Receptive

Language • Single-Word Expressive

Language • Naming of Body Parts • Comprehension of Oral

• Visual-Spatial Skills • Graphomotor construction • Reproduction of Block

Designs • Visuomotor Precision • Initial Learning • Recall of Verbal Information • Short-term Free Recall • Long-term Free Recall • Visual Memory • Basic Categorical &

Conceptual Knowledge

Case # 2 156





• Address Poor Performances

Defense Trial

157

Comparison of Performance Memory Testing

Performance on 11/9/99



Auditory Immediate

92 (30%)

94 (34%)

102 (55%)

Auditory Delayed

94 (34%)

102 (55%)

105 (63%)

Visual Immediate

84 (14%)

81 (10%)

91 (27%)

Visual Delayed

88 (21%)

75 (5%)

94 (34%)

Working Memory

76 (5%)

76 (5%)

83 (13%)

General Memory

93 (32%)

86 (18%)

150 (50%)

Board No. 1 158

Board No. 2

Memory Testing




Auditory Immediate

average

average

average

Auditory Delayed

average

average

average

Visual Immediate

average

average

average

Visual Delayed

average

average

average

Working Memory

low average

low average

low average

General Memory

average

average

average

Comparison of Performance

159

Board No. 3 COGNITIVE ABILITY

COMPARED TO PRE-ACCIDENT ABILITY, PERFORMANCE WAS:

Worse Consistent Better Auditory Immediate

Auditory Delayed

Visual Immediate

Visual Delayed

Visual Reproduction I

Visual Reproduction II

Working Memory

General Memory

160






• Advocate For Accountability

Defense Trial

161

Reduced Self-Control

No Control Over Impulse

(Disinhibition)

Disinhibition

(Irresistible Impulse)

162

Methodology

Irresistible

Not Resisted

163

Attack Methodology

“The line between an irresistible impulse and an impulse not resisted is probably no sharper than between twilight and dusk.”

U.S. v. Lyons, 731 F.2d 243, 248 (C.A. 5 (La) 1984), quoting American Psychiatric Association Statement

On The Insanity Defense, 11 (1982) [APA Statement.

164

Types Of Impulses

Irresistible

Not Resisted

(involuntary conduct)

(voluntary conduct)

165

Insanity Defense

M’Naghten Test Model Penal Code

17

14

Moral Incapacity 10

M’Naghten + Volition Product Mental Illness

3

1

Cognitive Incapacity 1

Clark v. Arizona, 548 U.S. 735, 126 S.Ct. 2709, 165 L.Ed.2d 842 (2006)

166

Need For Supervision

“... I can tell you that [plaintiff] is going to break those laws that will put him in some kind of facility within a very short time if he lived independently by himself. . . I don’t think it’s his cognitive skills that are the problem. I don’t think it’s his memory. . . I think it’s his impulsivity and his lack of self-control and his judgment that are damning him.”

Deposition of Beth Salcedo, MA, SLP, CCC, 6/10/09, p. 132, line 18 et seq

167

What is plaintiff’s I.Q.? Was plaintiff under influence of drugs, ETOH, meds? Does plaintiff recall his behavior? Did plaintiff understand physical act & consequences? Could plaintiff distinguish between right & wrong? Did plaintiff know “nature and quality” of the act? Did plaintiff know behavior was illegal? Did plaintiff believe behavior was immoral? Did plaintiff feel guilty? Did plaintiff plead guilty?

Establish Knowledge 168

Did plaintiff physically lose control over extremities? Did plaintiff plan or organize before (premeditated)? Was behavior self-endangering or self-defeating? Would plaintiff have waited if officer there? Did plaintiff lose all ability to control behavior? How much disinhibition is required for the behavior? How did you determine the impulse was irresistible?

Attack Volition 169

“There is, in short, no objective basis for distinguishing between offenders who were undeterrable and those who were merely undeterred, between the impulse that was irresistible and the impulse not resisted, or between substantial impairment of capacity and some lesser impairment.”

U.S. v. Lyons, 731 F.2d 243, 248 (C.A. 5 (La) 1984), quoting Bonnie, Moral Basis Of The Insanity Defense,

69 ABA J. 194, 196 (1983)

Attack Methodology 170






• Advocate For Accountability

• Attack Medical Studies

Defense Trial

171

Size Of Study

World Population 6,623,798,795

Australia Population 20,434,176

Study Population

122

Infants 27

Mild 4

172

American Children Under The Age Of 5

20,000,000

Cases Of TBI 50,000

Study Population

122

Infants 27

Mild 4

Size Of Study 173

Internet Abstract 174

Exclusion Criteria

Exclusion Criteria

• Previous TBI

• Pre-Existing Physical, Neurologic, Psychiatric, Or Development Disorder.

• Penetrating Head Injury

• TBI Caused By Child Abuse

175

Inclusion Criteria

Inclusion Criteria

• Age at injury (3 -13)

• Documented evidence of TBI including period of altered consciousness

• Ability To Complete Cognitive Evaluations

• Completions Of All Three Evaluations

176

Prior Study Exclusion Criteria

Earlier Study: Inclusion Criteria

Inclusion Criteria

• Age at injury (2-7)

• Documented evidence of TBI including period of altered consciousness

• Medical Records Sufficient To Determine Injury Severity

• Ability To Complete Cognitive Evaluations

• Completions Of All Three Evaluations

• English As First Language

• Parents Competent With English

177

Classifications 178

Classification Of Plaintiff 179

Control Group Performance 180

Did Better On 5/6 Tests !


Lower Lower


Within Standard Deviation!


traumatic brain injury: navigating litigation and...

Documents