手术并发症发生因素与医疗过错鉴定

医疗损害案件中因手术并发症而导致的占了很大的比重。发生手术并发症的发生原因可归结为医疗与患者两个方面。医疗方面的因素主要包括手术人员的责任心不强、医学基础知识欠缺、医疗技术生疏、诊断失误、术后护理及管理缺陷等;患者方面的因素主要有自身解剖变异、个体体质差异等。手术并发症产生的原因大多是可以被认知的,在此基础上判断产生手术并发症的医疗行为是否有过错时不能一概而论,应遵循一定的标准。建议按照医学理论和实际操作能力划分为两个标准,预见义务采用＂医学水平＂标准;防范义务采用＂医疗水平＂标准。通过两个＂标准＂来综合考量手术并发症才是科学的。     

Death due to a rare complication of colonoscopy and the potential medicolegal implications

A 64‐year‐old woman was found dead at home after undergoing a screening colonoscopy. At autopsy, 1.9 L of blood was discovered within her abdominal cavity. The only major abnormality was nontraumatic avulsion of the splenic capsule. This was the only identifiable abnormality capable of causing the severe hemoperitoneum and demise of the patient. Although rare, splenic capsule avulsion is a recognized complication of colonoscopy. Many have theorized that it results from excessive traction on the splenocolic ligament resulting in a tear of the splenic capsule. Most patients present within the first 24 hours after the procedure with nonspecific symptoms, and many patients may not seek medical attention. The paucity of the literature in the area of splenic capsular avulsion after colonoscopy reinforces the importance of reporting known cases, and by doing so raise awareness of this rare but devastating complication of an otherwise beneficial screening procedure.     

Human Cutaneous Myiasis by the Australian Sheep Blowfly,Lucilia cuprina (Diptera: Calliphoridae), in Oklahoma

This case report describes an incident of myiasis in Oklahoma City, Oklahoma. Paramedics treated a 53‐year‐old man in the field when he suffered cardiac arrest. He was intubated by the paramedics and transported to an emergency room, where he received two stents and a balloon pump. He was found to have a GCS of three and remained in the hospital for 7 days before passing away. After his death, the breathing tube was removed, revealing the presence of several maggots. On closer inspection, the dipteran larvae were found in both the oral and nasal cavities. Four of these larvae were reared to adulthood and identified as Lucilia cuprina (Weidemann) (Diptera: Calliphoridae), commonly known as the Australian sheep blowfly, by the Biology Department of the University of Oklahoma. Based on the fly's life cycle and rate of development, the infestation is suspected to be hospital acquired.     

Previously Unreported Complication of Coronary Artery Bypass Grafting: Suture Rupture Resulting in Patient's Death

Traditionally, the manner of death in most hospital autopsy cases is natural, in which death is due to the natural course of disease or reasonably anticipated outcomes of medical interventions. Some cases fall into a potential gray zone between natural and accident, including rare or unanticipated outcomes of medical interventions. We present a case of a patient postcoronary artery bypass graft. Autopsy revealed the proximal anastomosis of the aorta‐to‐first‐diagonal‐coronary‐artery‐to‐second‐obtuse‐marginal‐artery graft was detached from the aorta. A broken suture was present at the disconnected anastomosis, with intact knots but was broken along its length. In‐hospital mortality rates of CABG range from 1% to 3%, with several autopsy studies identifying surgical complications as the cause of death in one‐third of perioperative deaths. No publications were found that described suture rupture as directly relating to the cause of death. This case report describes a previously unreported complication of coronary artery bypass grafting.     

A Fatal Shot with a Signal Flare—A Crime Reconstruction*

Abstract: A reconstruction of an incident of a fatal wounding of a football fan with a parachute flare was performed. Physical and chemical examinations of the victim’s trousers and parts of a flare removed from the wound in his leg were performed by means of an optical microscope and a scanning electron microscope coupled with an energy dispersive X‐ray spectrometer. Signs of burning were seen on the front upper part of the trousers, including a 35–40 mm circular hole with melted and charred edges. Postblast residue present on the surface of the trousers contained strontium, magnesium, potassium, and chlorine. Also the case files—the medical reports and the witnesses’ testimonies—were thoroughly studied. It has been found that the evidence collected in the case supported the version of the victim being shot by another person from a distance.     

从医疗诉讼看医疗事故技术鉴定存在的问题与对策

由于医疗纠纷诉讼案件审理内容的特殊性,一般情况下在审理过程中都进行医疗技术鉴定。各地医学会组织专家进行鉴定,但由于医学会的复杂身份及制定的不完善,导致鉴定结论公信性、公平性、公正性和法律性不强。对此笔者建议应当从资格审查、法律责任、出庭质证、社会监督四个方面完善相关的法律制度,建立健全的监督机制。以保证医疗诉讼案件的公正、公平审理。     

Retropharyngeal Hematoma Secondary to Cervical Spine Surgery: Report of One Fatal Case

A 53‐year‐old woman suffering from radicular pain due to cervical herniation underwent a spinal surgery consisting of anterior cervical discectomy and fusion with an implantable titanium cage. Five hours after the procedure, the patient developed cervical swelling and dyspnea. An emergency surgery permitted evacuation of a deep cervical hematoma and intubation of the patient, who died some minutes later. The family of the deceased lodged a complaint with the public prosecutor because of unclear circumstances of death. After analysis of the medical records by two forensic pathologists, a medicolegal autopsy was ordered. Massive retropharyngeal and mediastinal hematomas were diagnosed. Pathological study confirmed acute cervical hemorrhage, but failed to detect the source of bleeding. The forensic pathologists concluded that death was due to mechanical asphyxia secondary to pharyngeal compression by the cervical hematoma. To the best of our knowledge, death secondary to retropharyngeal hematoma in this neurosurgical context is rarely encountered.     

Delay of clinical manifestation and medical malpractice in a serious vascular complication of proximal locked tibial nailing

We are reporting on a case of complex lesion of the popliteal neurovascular bundle in a young woman, resulting from an operation for reduction and synthesis of a closed spiroid fracture of the mid-distal third of the left tibia by means of a Grosse-Kempf nail, with significant delay of clinical manifestation. Determining whether this is an "unavoidable complication" or "medical malpractice" is the target of the forensic investigation. In this case, the investigation leads to the conclusion that medical malpractice was the only explanation of the damage.     

从法医角度看医疗纠纷及其产生的原因与防范

从医疗纠纷鉴定人角度研究医疗纠纷,为相关机构防范医疗纠纷提供思路。医疗纠纷是多种原因引起的,一般采用诉讼方式解决。法医在医疗纠纷的解决中扮演重要角色。在医疗纠纷鉴定中要判定诊疗行为对患者造成的损害后果,判定诊疗行为是否存在医疗过失,判定医疗过失与损害后果之间的因果关系．正确地进行死因分析和证据的取舍认定。在引起医疗纠纷的原因中,以技术性、责任心、医患交流不足等方面的原因居多。医护人员应提高自身的业务水平、责任心及服务质量;加强医患交流,建立畅通的医患沟通渠道;增强自我法律防护意识,建立健全的医疗规章管理制度。     

病历法律评估研究

由于病历在医疗纠纷处理中具有核心证据价值,因而在医疗纠纷愈演愈烈的大背景下,医患双方对病历的证据效力的争执也变得日益复杂。由于法律专业人士不具有医学专业知识,因而对病历的真伪及证据价值的判断显得无能为力,为了正确判断病历的证据价值,为了更好地使用病历作为认定案件事实的依据,因而迫切需要启动病历法律评估。病历法律评价应当坚持全面性、整体性、规范性和不苛求的原则,由有相关专业知识和背景的专业人士依照法定程序,采用专业评估方法,对病历的完整性、规范性和客观性进行评价,并提出专业性的评估意见。     

To Test or Not To Test?: The Value of Toxicology in a Delayed Overdose Death

A case demonstrating the necessity of thorough death investigation processes where toxicology plays an active role is presented. A 33‐year‐old white man presented to the emergency room in respiratory distress after an overdose episode where he was revived on the scene by fire rescue. His condition continued to deteriorate and he expired 6 days after the initial incident. No admission specimens were available for testing; however, there were specimens drawn 4 and 5 days after the incident. Drug paraphernalia from the scene was obtained by the laboratory through collaboration with local law enforcement. Drug paraphernalia was initially tested in the laboratory and after obtaining the results, the antemortem and postmortem specimens were tested identifying mitragynine and U‐47700, among other drugs. These results indicate the value in obtaining and testing drug paraphernalia, and the value of testing antemortem specimens even in the event of a delay.     

宫内节育器使用所致医疗纠纷法医学鉴定

在法医鉴定中,由宫内节育器引发的医疗纠纷案例逐年增加,患者法律保护意识、医务人员的技术水平较低是此类鉴定增加的主要原因。目前宫内节育器仍然是我国妇女避孕的主要途径之一,宫内节育器医疗操作中可能发生的并发症或意外及其与医疗行为的关系,医院是否需要承担责任及责任大小等均需要明确。加强医生技能训练,采取必要的防范措施,客观评价和认识宫内节育器诊疗中的并发症,才能确保计划生育工作宫内节育器的安全可靠。     

Mock Defendants' Procedural Justice Judgments of Alternative Trial Procedures in a Medical Malpractice Case

Mental health professionals were asked to imagine themselves in the role of defendant in a medical malpractice case. Each participant was told that their case could be tried according to standard adversary trial procedures or by an alternative procedure. The alternative procedures involved either varying the way that expert testimony would be developed or bifurcation of issues at trial. Participants rated the available alternative procedure relative to the ADVERS procedure in terms of preference, fairness, willingness to comply with trial outcomes, and other procedural justice dimensions. Results indicated a strong endorsement of potential alternatives to the standard adversarial trial process for resolving medical malpractice claims.     

Air embolism following arthroscopy--autopsy findings and forensic medicine aspects

An iatrogenic cause of air embolism with a fatal outcome is reported that occurred in a case in which arthroscopy of the knee had been carried out. Even after worldwide use of arthroscopy for many years, this complication has never been seen until now. At autopsy, when air bubbles were observed in the right heart chamber and in the vena cava inferior, only the knee joint was taken into consideration as the air-access route. The access of air was detected by means of arthroscopy on the corpse, combined with a special autopsy technique and shown experimentally. Insufflated air had entered via a fracture of the tibial articular surface and then passed through the spongiosa into the femoral vein. These findings are of far-reaching clinical consequence because the indication for arthroscopy by gas insufflation must be reconsidered again. Finally, the medicolegal aspects of such an incident are discussed.     

Fatal Venous Air Embolism Following Intravenous Infusion*

Abstract: Venous air embolism has been reported as a complication of invasive diagnostic and therapeutic procedures or accidental trauma. Little is known about the incidence of air embolism after minimal intravenous manipulations such as the insertion of a peripheral intravenous cannula. Only when large amounts of air sufficient enough to block the cardiovascular system enter, the patient develops symptoms and signs of severe neurological injury, cardiovascular collapse, or death. The dead body of a 14‐year‐old boy was brought for postmortem examination with allegations of death from negligence during treatment. He was treated for pain in the abdomen in a hospital by attendants in telephonic consultation with a medical practitioner. Following intravenous infusions, the boy died suddenly in respiratory distress. Gross findings indicated the death to be from venous air embolism. Chemical analysis, histopathology, and microbiology ruled out other causes of death. Dilemmas of the case with difficulties in diagnosis are being presented herewith.     

一起医疗纠纷引发的民事诉讼和行政复议案的思考

以一起医疗损害赔偿纠纷案件引发的民事诉讼和行政复议为例,分析了案例中的几个焦点问题,包括卫生行政部门是否有权审核民事诉讼中的鉴定行为及鉴定结论、是否可以根据民事审判结果做出行政处罚等。强调卫生行政部门应当注意民事诉讼和行政复议的关系,避免出现行政干预司法的违法行政后果,并在此基础上总结了几点办案体会。     

知情同意理论中医生说明义务的构成

医疗损害赔偿范畴内的知情同意理论是从医患关系之利益依赖模式为基础而建立的 ,具有医学伦理和医疗法律、消级性和积极性等不同层面的功能。知情同意作为医患之间的权利义务关系具有整体性 ,可构成责任基础和权利请求的独立根据。而知情同意范畴内医生说明义务 ,应以其作为有效同意之逻辑前提为宜 ,将“知情同意。作为一整体性独立义务施加于医疗机构。医生的说明义务履行充分性的判断应以理性医生标准为基础 ,并充分平衡病人标准对病人利益为保护     

Re‐Claiming Disability: Identity,Procedural Justice,and the Disability Determination Process

This research highlights the crucial role of an intimate link between a disabled person's self‐identity and the perceived fairness of legal procedures. In doing so, it brings to the foreground a wholly ignored aspect of procedural justice. Earlier researchers have failed to delve into the role identity politics plays in the relationship between the institutions and the beneficiaries of their services, and the way different members of a group understand and define themselves. This research explores the way people with disabilities in the United States, with different kinds of disability identities, experience and evaluate the procedure of claiming Social Security benefits. The findings suggest that disabled people who identified with the social model of disability (as opposed to the medical‐individual models) hold a critical view of the procedure for retaining benefits. They felt they had no control over it, could not voice their opinions, were mistreated by representatives, and had to present an image that was not necessarily true of their disability. They also saw the procedure as discouraging them from participating fully in the labor market, and consequently integrating better in society, an idea that was not present among disabled people who identify with medical‐individual models. Exposing this relationship between the way people perceive themselves and the way they experience and evaluate legal procedures can contribute to the creation of better policies, while improving communication between the state and members of the disability community, along with other marginalized groups.     

Medium‐Chain Acyl‐CoA Dehydrogenase Deficiency in Adulthood: A Potential Diagnosis in a Patient with Mental Status Changes Suspected of Drug Toxicity

Medium‐chain acyl‐CoA dehydrogenase (MCAD) deficiency is a rare but important component of the differential diagnosis for adults with a history of premortem mental status changes and the postmortem finding of hepatic steatosis. This case report describes a 30‐year‐old white man who, following a period of nausea and vomiting, was admitted to the hospital with sudden mental status deterioration followed rapidly by clinical deterioration and death. Treating physicians in this case suspected acute illicit drug toxicity with synthetic cathinones based on social history. Clinicians and medical examiners should be aware that the presentation, signs, and symptoms described may indicate an underlying inborn error of metabolism such as MCAD deficiency and take action accordingly.     

Small bowel perforation as a complication of microsurgical lumbar diskectomy. A case report and brief review of the literature

Ventral perforation is a rare complication of lumbar diskectomy. Injury to retroperitoneal vessels is the most common serious complication to such perforation. Ventral perforation with damage to the bowel is rarely reported. The authors present the first case report of injury to the small bowel during a microsurgical lumbar diskectomy. The case illustrates the importance of awareness of bowel injury as a possible complication of diskectomy. Possible pre- and postoperative considerations are also discussed. A brief review of the literature on bowel injuries after this common surgical procedure is also given.