Traumatic Brain Injury Demand Letter
o) Right Femoral Head Fracture with Posterior Subluxation
Dr. Rosemary Carlille diagnosed Brian upon admission to Memorial on August 25, 1997, with a posterior dislocation of the right femoral head with associated right femoral head fracture. It was later discovered by Dr. Trujillo that Brian had also fractured his right acetabulum. Dr. Carlille performed the attempted closed reduction of the right hip and Steinmann pin application in order to avoid avascular necrosis. During the emergency procedure Dr. Carlille was able to get the hip reduced, but it was extremely unstable. She placed a 3/16 threaded Steinmann pin into the skeletal tibial retraction, but the hip remained partially subluxed. Because of Brian's other emergent injuries, including his head and abdominal injuries, his hip situation was addressed when he became more stable.
Brian underwent surgery on September 2, 1997, to repair the right femoral head fracture. Dr. Allen Battalini was consulted to perform a right bipolar hemiarthroplasty. He began by approaching the hip with a posterolateral incision. The skin incision was made using a scalpel followed by meticulous hemostasis using electrocautery.
As Dr. Battalini viewed the greater trochanter as well as the iliotibial band of the gluteal muscles, it became necessary to gain additional visualization of the hip by the making of a greater trochanteric osteotomy.
The osteotomy was performed by cutting out a wedge-shaped segment of the bone shaft causing a change in the angulation of the part of the bone above the cut. This shifted the angle of the sharply-sloping fracture plane to a more nearly-horizontal position, thus giving the upper fragment a more level position from which it is less likely to slip downward. The greater trochanter was then reflected and held in position with Steinman pins placed in the superior aspect of the acetabular dome of the pelvis.
Dr. Battalini then noted that there was a large anteromedial fragment as well as multiple small fragments among the superior medial aspect of the femoral head. He attempted to reconstituate the bony architecture of the femoral head with the remaining pieces, but a large articular defect was noted on the superior medial aspect of the femoral head. Since the femoral head is a significant part of the weight-bearing portion of the articular surface, attempts at reconstructing the femoral head through open reduction were abandoned given the lack of possible recreation of articular congruency and significant femoral head damage.
Dr. Battalini then severed the femoral neck using an oscillating saw with a plan for placement of a bipolar hemiarthroplasty. Once the femoral neck and head was severed, a trial head and bipolar component was placed and a reduction performed of the hip. It was noted to be stable with this construction. Dr. Battalini then removed the implants and copiously irrigated the hip canal using normal saline solution. The bipolar head and cup were then placed back in the hip and secured with impaction. Dr. Battalini noted that Brian tolerated the procedure well. However, Brian has been informed that bipolar hemiarthroplasty is normally a compromise, good for merely five years, and requires regular replacement every five years thereafter. Therefore, it is estimated that Brian will require numerous replacement hemiarthroplasties throughout his life expectancy.
Regardless of Brian's prognosis for future hip treatment, his chances of secondary osteoarthritis are significantly greater now that he has fractured his hip. Secondary arthritis is considered an acceleration of primary arthritis. The condition is extremely painful and crippling and the only remedy is further arthroplasty.
p) Fractured Acetabulum
Dr. Trujillo noted a fracture of the posterior acetabular lip. The acetabulum is the cup-like hollow at the side of the innonimate bone that acts as the socket into which the head of the femur fits to constitute the hip joint. The acetabulum is divided into three components: the ischium part of the acetabular cavity is designated the posterior pillar; the pubic ramus area of the cavity is the anterior pillar; and the ilium is the superior pillar. The most important pillar in relationship to hip stability is the posterior pillar. Thus, proper treatment of Brian's fractured posterior acetabular lip is of utmost importance in relation to hip stability.
q) Multi-focal Contusions
The multiple blows to his head caused Brian to suffer contusions of the brain in the right frontoparietal vertes, the left tectum, and the left lobe frontal area. These continue at this time to contribute to the brain problems from which he suffers.
r) Frank Seizures
Brian suffered several seizures during his hospitalization and will remain on seizure medication for the remainder of his life in order to avoid the recurrences.
s) Heterotopic Ossification
Heterotopic ossification is a formation and subsequent displacement of bone in soft tissue. In Brian's case, Dr. Battalini noticed a large anteromedial fragment as well as multiple small fragments among the superior medial aspect of the femoral head during Brian's right bipolar hemiarthroplasty. These bone fragments subsequently ossificated and continue to cause Brian significant pain.
Dr. James Donovan of B.R.R.I. noticed extensive heterotopic ossification involving the medial and lateral aspects of the joint. In a later impression, Dr. Scott Hiemburtnoticed that the heterotopic ossification around the right hip had increased. This will continue into the foreseeable future and Brian will suffer increasing pain as the ossification increases. Future surgeries to clear the bone fragments are necessary.
2. Additional Sequelae of Personal Injuries
Dr. Timothy Majors performed a complete neuropsychological work-up on Brian on January 22 and January 29, 1998. His evaluation is attached, but excerpts are produced below.
a) Severe Neurocognitive Impairments
In a report dated February 13, 1998, Dr. Majors stated:
His CT scan at the time of the accident revealed a subarachnoid hemorrhage and multi-focal contusions. A repeat CT scan on August 26, 1997, was positive for a right frontal subcortical shear injury. Following the accident, he developed a seizure disorder and was treated with anticonvulsant medications. Mr. Forrester was admitted to St. Elmo's Hospital in November of 1997 in order to have a ventricular shunt placed in order to treat communicating hydrocephalus. The nature and severity of these neurological complications are characteristic of a severe head injury and are indicative of a very guarded prognosis. Mr. Forrester was referred to me by his neurologist, Dr. Brent Galloway, for a comprehensive neuropsychological evaluation. My evaluation was conducted on January 22 and 29, 1998. The results of my evaluation indicated that Mr. Forrester is suffering from the sequelae of a severe head injury and is experiencing severe neurocognitive impairments as a result of the brain damage which he suffered.
b) Severe Memory Problems
Dr. Majors stated:
As is typical of most severe head trauma injury, Mr. Forrester has severe impairments in rote verbal memory and logical verbal memory.
- Severely impaired rote verbal memory
- Severely impaired logical verbal memory. My test results indicated that he has severe deficits in the storage and retrieval of verbal information.
- Severely impaired storage of verbal information.
In addition, there were severe impairments in visual reconstruction memory.
- Severely impaired retrieval of verbal information
- Severely impaired visual reconstruction memory
c) Impaired Speed of Processing Information
Dr. Majors stated:
The second major area of neurocognitive impairment is in speed of processing information...On all tests which involved a speed component, Mr. Forrester was quite slow for his age and intellectual ability. He was particularly slow in processing visual information, although his processing of oral information was also somewhat reduced.
d) Impairment of Executive Functioning
Dr. Majors stated:
Perhaps the most significant area of neurocognitive impairment is that of executive functioning. Executive functioning refers to a large group of cognitive skills which are involved in the execution of goal-directed behavior. Our tests indicate that Mr. Forrester is having difficulty engaging in abstract problem-solving behavior...when he is exposed to novel and unstructured situations, he has difficulty analyzing the situation, recognizing alternative courses of action and choosing the most effective alternative. Other areas of executive dysfunction include reduced planning and organizational skills, poor awareness of his cognitive impairments, reduced initiation and follow-through and difficulty setting goals and making decisions. Mr. Forrester's impairments in executive functioning will prevent him from engaging in the highly sophisticated computer analysis and consultation in which he engaged as a professional. In fact, his executive dysfunctions are so severe at the present time that he is not a candidate to return to work in the foreseeable future.
e) Severe Depression
On the standard multiaxial diagnosis under Axis I, Dr. Sasha Styles diagnosed Brian with a major depression with psychotic features. Dr. Styles's diagnosis was made on October 18, 1997, while Brian was a patient at B.R.R.I.
In his neuropsychological workup on January 22 and January 29, 1998, Dr. Timothy Majors diagnosed Brian's Axis I difficulties as 296.23 major depressive disorder, single episode, severe without psychotic features. The distinction between the two diagnoses is the existence of psychotic features in October and their absence in February. The psychotic features to which Dr. Styles referred were perceived homicidal and suicidal tendencies experienced by Brian, primarily during the time when he was heavily sedated. In fact, he has no recollection of such tendencies. By the time he came under the neuropsychological care of Dr. Majors in January, 1998, these psychotic features had resolved.
The multiple bases of severe depression suffered by Brian include concern over his medical and physical condition, his career concerns, his loss of confidence and self-esteem, and his fear of economic consequences. He also can no longer relate to pleasure and is dysphoric and socially withdrawn.
Brian continues to suffer many ailments on an ongoing basis, and has experienced other difficulties since the collision, some of which are listed below:
Left Temporal Lobe Slowing;
Frequent Severe Headaches;
Gastrointestinal Complications;
Severe Neck, Back and Head Impairments;
Tachycardia with Hypertension;
Spiking Fevers;
Urinary Tract Infections;
Profound Neutropenia;
Infectious Disease;
Erythematous Rash;
Persistent Physical Pain; and
Permanent Mental Anguish;
D. SURGICAL PROCEDURES - PAST
1) DATE: 8-25-97
DIAGNOSIS: Elevated Intracranial Pressure; Closed Head Injury
PROCEDURE NO. 1: Right frontal Camino Bolt Placement
DOCTOR: Dr. Frank Waterhouse
DIAGNOSIS: Right Hip Fracture Dislocation Including Femoral Head Fracture
PROCEDURE NO. 2: Attempted Closed Reduction of the Right Hip; Steinmann Pin Application
DOCTOR: Dr. Rosemary Carlille
DIAGNOSIS: Status Post-trauma With Hemoperitoneum With Blunt Injury of the Right Colon
PROCEDURE NO. 3: Exploratory Laparotomy
PROCEDURE NO. 4: Right Hemicolectomy with Primary Ilealcolectomy
PROCEDURE NO. 5: Placement of Jejunostomy Tube
DOCTORS: Dr. Benjamin Trujillo - Surgeon
Dr. Todd Rogers - Resident
******************************************************************
2) DATE: 9-2-97
DIAGNOSIS: Right Femoral Head Fracture, Pipkin Type II
PROCEDURE NO. 6: Greater Trochanteric Osteotomy
PROCEDURE NO. 7: Right Bipolar Hemiarthroplasty
DOCTORS: Dr. Christopher Battalini - Surgeon
Dr. Kelly Doons - Co-surgeon
*****************************************************************
3) DATE: 11-18-97
DIAGNOSIS: Post-traumatic Hydrocephalus
PROCEDURE NO. 8: Placement of a Right Parietotemporal Ventriculoperitoneal Shunt
DOCTOR: Dr. Anthony Curtis
E. SURGICAL PROCEDURES - FUTURE
1) Neck Surgery
2) Back Surgery
3) Steinman Pin
4) Shunt Adjustment - Replacement
F. HEALTH CARE PROVIDERS
Brent B. Galloway, M.D.
Board Certified, Neurology
7707 Primrose Drive, Suite 1020
Springfield, Texas 55555
(555) 555-5555
Timothy Majors, Ph.D.
7707 Primrose Drive, Suite 200
Springfield, Texas 55555
(555) 555-5555
Sasha Styles, M.D.
Board Certified, Psychiatry and Neuropsychology
900 Crosswood, Suite 293
Springfield, Texas 55555
Macy F. Weinert, M.D.
Board Certified, Internal Medicine - Infectious Diseases
55555 Primrose Drive, Suite 1540
Springfield, Texas 55555
(555) 555-5555
Benjamin H. Trujillo, M.D.
Board Certified, General Surgery, Traumatic Surgery
55555 Primrose Drive, #4.286
Springfield, Texas 55555
(555) 555-5555
Christopher R. Battalini, M.D.
Board Certified, Orthopaedic Surgery
55555 Primrose Drive, #450
Springfield, Texas 55555
(555) 555-5555
Anthony J. Curtis, M.D.
Board Certified, Neurological Surgery
St. Elmo's Towers
55555 Primrose Drive, Suite 2340
Springfield, Texas 55555
(555) 555-5555
Crystal S. Cox, M.D.
Board Certified, General Surgery, Surgical Critical Care
55555 Primrose Drive, #4.167
Springfield, Texas 55555
(555) 555-5555
Arthur G. Horowitz, M.D.
Board Certified, Ophthalmology
Ana Perez
Neuro-optometrist
SEEVIEW EYE CONSULTANTS
55555 Primrose Drive
Suite 1501
Springfield, Texas 55555
(555) 555-5555
Dr. Frank J. Waterhouse
55555 Primrose Drive, #1202
Springfield, Texas 55555
(555) 555-5555
Gerard Quiznos, M.D.
James V. Donovan, M.D.
David Goller, E.M.D.
Seung K. Park, M.D.
Scott D. Meshberger, M.D.
Julie Wendt, M.D.
Ellen Lamki, M.D.
Board Certified, Diagnostic Radiology
Linda Fahr, M.D.
Kelly Eldred, O.D.
James Willmore, M.D.
Board Certified, Neurophysiology
Lance Carmichael, M.D.
Cindy Ivanhoe, M.D.
Kenneth C. Parsons, M.D.
Jenny Lai, M.D.
William H. Donovan, M.D.
Kenneth C. Parsons, M.D.
B.R.R.I.
1333 Boursund
Springfield, Texas 55555
Brent E. Masel, M.D.
Jeremy S. Caroselli, Ph.D.
Dorothea A. Everett, P.T., M.A.
The Temple Learning Center at Llanview
P. O. Box 55555
1528 Costoff
Llanview, Texas 55555
1-800-555-5555
C. Depray, M.D.
J. Chalk
Neurophysiology
Joshua M. Cohn, M.D.
Rosemary Carlille, M.D.
Board Certified, Orthopedic Surgery
Todd Rogers, M.D.
Kelly Doons, M.D.
Rosanna Lapham, M.D.
Board Certified, Pathology
Anwar Farhood, M.D.
James Wheeless, M.D.
Neurology
David L. Zelitt, M.D.
Radiology
Luceil B. North, M.D.
Larry A. Carmichael, M.D.
Linda Hankins, M.D.
Kathryn A. Zider, M.D.
Marilyn Nelson, M.D.
Nelson Valena, M.D.
Samia Khalil
Anesthesiology
Memorial
55555 Primrose Drive
Springfield, Texas 55555
(555) 555-5555
St. Elmo's Episcopal Hospital
55555 Bertner
Springfield, Texas
(555) 555-5555
Laurens R. Pickard, M.D.
55555 Primrose Drive, #1612
Springfield, Texas 55555
(555) 555-5555
Ameristat Gulf Coast
P. O. Box 55555
Springfield, Texas 55555
American Medi Response
P. O. Box 55555
Springfield, Texas 55555
Bakersfield Health Department EMS
55555 W. Mefee
Bakersfield, Texas 55555
(555) 555-5555
University of Texas Health Science Center Springfield
55555 Primrose Drive
Springfield, Texas 55555
(555) 555-5555
Joe Segel, M.D.
P. O. Box 55555
Springfield, Texas 77216-0593
Luis Orosco, M.D.
Greater Springfield Anesthesiology
P. O. Box 55555
Springfield, Texas 77005
Shiao Y. Woo, M.D.
Methodist Hospital
55555 Norfolk, Suite 910
Springfield, Texas 55555
(555) 555-5555
Tomas Klima
Southeast Texas Pathology Associates
P. O. Box 55555
Springfield, Texas 55555
(555) 555-5555
