Saturday, July 04, 2009
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Burns - Industrial Accident Demand Letter

Industrial Accident

Demand Letter

V. EVIDENCE OF DAMAGES - Harry Hunter

A. SYNOPSIS OF PERSONAL INJURIES

1. Burns over 78 % of total body surface with inhalation injury.
2. Tinnitus;
3. Collapsed lung;
4. Diplopia;
5. Acute respiratory failure;
6. Closed head injury;
7. Anoxia from collapsed lung;
8. Anoxia from fume inhalation;
9. Shock from burn injuries;
10. Infection in lungs;
11. Cardiovascular edema;
12. Cardiac arrhythmia consistent with supra-ventricular tachycardia;
13. Preorbital edema (significant)
14. Retrograde amnesia
15. Cardiovascular complications
16. Spiking high fevers

B. SYMPTOMS OF CLOSED HEAD INJURY

1. Loss of consciousness
2. Post traumatic amnesia
3. Brain concussion;
4. Short-term memory loss
5. Confusion
6. Decreased attention span
7. Fatigue
8. Tinnitus
9. Hypersensitivity to noise
10. Blurred vision - left eye
11. Diplopia - left visual field
12. Hypersensitivity to unanticipated touch
13. Decreased range of motion - left side of body
14. Facial dysmorphia
15. Paraphasia - (speech disorder)
16. Mildly depressive mood
17. Flattened affect
18. Decreased tripod grip
19. Mild decline in memory functions
20. Difficulty with naming and word finding tests
21. Relative decline in verbal fluency
22. Slight sway in Romberg testing
23. Visual motor functioning within impaired limits
24. Bilateral motor functioning in grip - very poor
25. Disturbance in mood functioning
26. High levels of distress
27. Post - traumatic stress disorder
28. Mental sequelae of burn injuries

C. EVIDENCE OF BRAIN TRAUMA

Harry suffers from the effects of brain trauma which have three separate and distinct sources but which combine to cause him considerable difficulty and frustration. The multiple brain trauma also severely impacts his wage earning capacity, his enjoyment of daily living and is a considerable source of mental anguish.

First, Harry suffered a head trauma in the form of a cerebral concussion when, during his attempts to escape the fire, he fell down nine steps and was knocked unconscious when his head hit the concrete ramp at the bottom of the stairs. Secondly, he suffers from the neuropathologic changes in neurotransmission, neuroimmune response, and the effects of post-traumatic neurotoxins which customarily accompany severe burns and cause a number of neuropsychological changes. See the report of Dr. Pat Lewisson, Exhibit B, p.5. Third, Harry suffers from post-traumatic stress disorder which combines with cerebral concussion and the neuropsychological sequelae of severe burns to create a very adverse brain trauma scenario. These combined brain anomalies manifest in confusion, emotional lability, short-term memory loss, lack of organizational skills and a plethora of other adverse consequences which affect Harry's daily quality of life. Harry needs therapy in the future in order to learn the compensatory strategies necessary to cope with these permanent brain trauma problems.

With respect to treatment of the multiple sources of brain trauma which contribute to Harry's current cognitive difficulties, Harry was very fortunate to undergo neuropsychological examination by Dr. Pat Lewisson, a faculty member in the Department of Neurology, Neuropsychology Service of Divine College of Medicine in Dover, Texas.

On initial examination by Dr. Lewisson, Harry was experiencing difficulty with short-term memory loss, mild confusion, decreased attention span, fatigue, tinnitus, hypersensitivity to noise, blurred vision in the left eye, diplopia in the left visual field, hypersensitivity to unanticipated touch, decreased range of motion on the left side of his body, decreased dexterity and strength in the upper extremities associated with peripheral burns and generalized pain associated with burns. These symptoms, other than those obviously associated with burns, are totally consistent with neurophysiological and neuropsychological problems arising from a closed head injury.

On personality assessment testing, Dr. Lewisson found disturbance in mood functioning consistent with moderate levels of depression common to this population. He demonstrated high levels of distress associated with pain and physical complaints and found that anxiety and feelings of inadequacy were high. Dr. Lewisson also noted elements of post traumatic stress disorder and adjustment disorder associated with Harry's physical injuries. Exhibit B: Lewisson Report, p.5.

Post traumatic stress disorder is a traumatic neurosis which manifests as a group of characteristic symptoms that develop following a stressful situation. A jury will have no difficulty in agreeing that Harry was placed in a stressful situation by the negligence of the Forosukas.

The adjustment disorder to which Dr. Lewisson refers is a predictable group of maladaptive reactions to a stressful life crisis such as the extreme physical injuries from which Harry suffers. This disorder commonly accompanies severe burn trauma and is one of the recognized neurocognitive sequelae of such injuries. Both post traumatic stress disorder and adjustment disorder require therapy in order to cope with the consequences of the trauma. To date, Harry has had no such therapy due to the abysmally poor health care system in Canada.

Dr. Lewisson's evaluation of Harry tells the story of the effects of the traumatic brain injury most effectively:

Results point to a man with high levels of premorbid functioning who is demonstrating a constellation of neuropsychological problems largely associated with severe burns and to a lesser degree, cerebral concussion.Clinically prominent are motor limitations associated with praxis in the upper extremities, restricted range of motion, and perceptual difficulties with diplopia, tinnitus, and acoustic and tactile hypersensitivity....On verbal fluency and paraphasia, it appears some mild sequelae of concussion persist in these assessed areas because they are significantly below expected levels. Lewisson Report, p.4, Exh. B

In addition to the sequelae which result directly from the burns, there are a plethora of neuro- physiological ramifications which accompany severe burn injuries and Harry is exhibiting these also as revealed in Dr.Lewisson's examination:

Determining exact etiology of neurocognitive complaints in such burn cases involving cerebral concussion is difficult due to the neurophysiological changes which occur as a result of the severe burns. Neuropathologic changes in neurotransmission, neuroimmune response, and the effects of post-traumatic neurotoxins after such injuries cause a number of neuropsychological alterations. Lewisson, supra @ p. 5.

Post-traumatic emotional and affective aspects of the injury are significant and contribute to diminished neurocognitive functioning and subjective complaints but the patient tends to minimize and deny the emotional aspects of the injuries and their effects of his long-term well being and happiness, including the impact of the injuries on his marriage and family life. Lewisson, id.

Dr. Lewisson felt that the post-concussive aspects of Harry's injuries were resolving within expected recovery gradients but that Harry was a candidate for prolonged recovery due to his age, gender, and the nature and extent of his physical injuries.

Thus, Harry is now suffering neuropsychological sequelae from the combined effects of brain concussion; post - traumatic stress disorder; and neurophysiological sequelae of burn injuries. When this brain injury is overlaid onto the physical injuries, the combined effects are devastating, even to a man of Harry's courage and strong will to recover.

The distinguishing characteristics of traumatic brain injuries are that they are permanent and irreversible in that all three of the customary methods of treatment are ineffective: a) there is no surgical procedure to rehabilitate brain trauma; b) there is no pharmaceutical repair for brain trauma; and, c) the damaged and destroyed brain cells are non-regenerative. Therefore, Harry's brain injuries are permanent and irreversible. The treatment of choice is to train Harry in compensatory strategies which will allow him to partially compensate for deficiencies which resulted from the blow to the head which knocked Harry unconscious as he fell down nine steps in trying to escape the fiery pit.

D. MEDICAL PROOF REGARDING BURNS

Considering the extensive nature and severity of the burns suffered by Harry Hunter (78% TBSA) we anticipate at least one full day of medical testimony concerning burn injuries. Our principal medical witness will educate the jury with respect to the horrors of burns. The reasonable value of medical services rendered to date to correct the devastating effects of the burns total in excess of Four Hundred Thousand ($400,000.00) Dollars. The total lifetime medical costs for correction of the damage to Harry Hunter will exceed Six Hundred Thousand ($600,000.00) Dollars. Thus, we plan to fully educate the Texas jury with respect to the following elements of burns:

1. Burns

a. Etiology of Harry Hunter's Burns

The etiology and physiology of Harry's burns consist of the severity of the charred skin which is related to depth, extent, percentage of body surface burned, age, and parts of the body affected. The depth of Harry's injury is directly related to the temperature of the burning agent and the duration of contact with the body tissue. Below 112 degrees Fahrenheit, no local damage occurs unless exposure is for a protracted period. Between 112 degrees and 151 degrees Fahrenheit, the rate of cellular destruction doubles with each one degree rise in temperature. A full thickness burn may occur in as little as one second of exposure depending on the degree of the heat. In this case, the heat to which Harry was exposed exceeded 1,800 degrees and the burning of his flesh was immediate and severe.

b. Burn Categories

Harry's burns are classified in three different categories:

(1) Superficial partial-thickness burns (First degree): These burn injuries involve the top layer of skin, the epidermis.

(2) Partial-thickness burns (Second degree): These burn injuries involve the epidermis and upper portions of the dermis. Some of the dermal appendage may remain, from which the wound may spontaneously re-epithelialize.

(3) Full-thickness burns (Third degree): In these severe burn injuries, all layers of the skin and often the underlying tissues are destroyed. Several grafting procedures were required to close the multiple severe wounds which Harry experienced.

c. Physiology

The physiologic reaction that occurs when skin is burned consists of adjacent, intact blood vessels dilating. Platelets and leukocytes begin to adhere to the vascular endothelium as an early event in the inflammatory process. Increased capillary permeability produces wound edema, with an influx of leukocytes and monocytes. If Harry receives proper medical treatment, eventually new capillaries, immature fibroblasts and newly formed collagen fibrils will appear within the wound and will support the regeneration of the epithelium. If this does not occur, Harry will face further surgical intervention.

d. Alterations in Body Systems

In addition to charred skin in the local burned area, there were major alterations and disruptions in the vascular and other systems of Harry's body. The water vapor barrier for his body is the outermost layer of the epidermis and infections and severe reactions from fluid loss occurred. Capillary permeability increased, permitting fluid and protein to move from the vascular space into the interstitial spaces, causing considerable swelling as seen in many of Harry's photos. With this reduced vascular volume, Harry went into shock and could have died within minutes. Other complications will result in death to the skin from rotting necrosis. Harry was initially life threatened by alterations in his body systems.

e. Complications Concomitant

Harry was life threatened by the complications which accompanied his severe burn injuries. The primary causes of morbidity and mortality in burn victims are those related to skin infection and pulmonary problems. Therefore, intravenous antibiotics were given to Harry prophylactically to prevent gram-positive infection, and topical antibacterial agents were applied to help retard the proliferation of pathogenic organisms until wound closure could occur spontaneously and eventually through surgical intervention. The complications which confronted Harry included the following:

(1) Hemodynamics: Lessened circulating blood volume resulted in decreased cardiac output from the heart and increased heart rate. This resulted in inadequate tissue perfusion which caused acidosis, renal effects and burn shock.

(2) Metabolic demands: A breakdown of cells resulted in the threat of liver and muscle glycogen becoming exhausted within the first few days.

(3) Renal effects: Glomular filtration is decreased and threatened complete renal shutdown and failure of the kidneys.

(4) Hematology effects: Thrombocytopenia, abnormal platelet function, and deficit in several plasma clotting factors threatened bleed outs and anemia from occult blood loss.

(5) Immunologic effects: The loss of the Harry's skin barrier and presence of eschar, dead rotting skin, favored bacterial growth. An abnormal inflammatory response after a burn injury caused a decreased delivery of antibodies, white blood cells and oxygen, hypoxia and acidosis, thrombosis of vessels in the wound area and impairment of the body's resistance to bacteria.

(6) Burn wound sepsis: Colonization of the burn wound by bacteria, subeschar and intrafollicular colonization developed and invaded subadjacent nonburned tissue, seeding bacteria from the wound. This colonization constantly threatened systemic septicemia.

f. Treatment of Burn Complications

Three major considerations in Harry's treatment regimen were prevention of infection, avoidance of pulmonary damage and rehabilitation. Harry had to undergo hemodynamic stabilization, metabolic support, wound debridement, use of topical antibacterial therapy and biologic dressings and wound closure. Other vitally important measures were followed during Harry's difficult course of treatment, including:

(1) Burn wounds were cleansed daily with an antibacterial cleansing agent and saline solution. This was excruciatingly painful to Harry daily.

(2) Nonviable tissue (eschar) was removed through enzymatic, mechanical or surgical debridement. Burn eschar began to separate from the underlying viable tissue by a natural process of bacterial growth, which caused a lysis of protein at the viable - nonviable tissue interface. Eschar was also removed through daily dressing changes with forceps and scissors during wound cleansing.

(3) Harry experienced several procedures involving removal of nonviable tissue down to a viable base, then covering it with a biologic dressing, heterograft, homograft or autograft from the nonburned portions of his body.

(4) Topical antimicrobials had medication applied to cover burn areas and reduce the number of organisms. However, some of the gram negative bacilli became highly resistant to the antimicrobials, placing Harry in jeopardy of life threatening infections.

(5) Split-thickness grafts were harvested from human cadavers and used in Harry's grafting procedures.

(6) Allograft is a graft of skin taken from another person or a cadaver and applied to a burn wound temporarily. In Harry's case he had grafts that were taken from a cadaver since he had burns over 78% of his body and did not have a sufficient source of nonburned skin to meet the need for grafting. The grafts from the cadaver were applied to Harry's skin and held with staples and gauze until they grew into the skin.

(7) Broad spectrum antibiotics were necessary to combat systemic gram positive and gram negative infections and sometimes fungal infection which could appear at any time and further endanger Harry from life threatening infections. Since Harry was in extreme jeopardy from the possibility of infections, critical diagnostic parameters were followed including the following:

(a) qualitative wound inspection and biopsy
(b) bronchial inspection and biopsy
(c) blood culturing
(d) sputum cultures
(e) temperature monitoring
(f) changes in behavior, hallucinations or confusion

(8) In severe burn injury from fire sources, there is a high index of suspicion for smoke inhalation injury. It was imperative to have an evaluation by a chest x-ray, blood gas levels, and bronchoscopy to confirm mucosal erythema, hemorrhage, ulceration, edema, presence of carbonaceous particles, or soot in oropharyngeal passages or production of dark gray sputum.

(9) Harry experienced impaired gas exchange related to carbon monoxide poisoning, upper airway obstruction, smoke inhalation and/or edema of the lung.

(10) Prolonged intubation connected to mechanical ventilation was necessary for adequate exchange of oxygen and carbon dioxide.

(11) Bronchial suctioning was required to flush out toxic sputum which harbors bacteria.

(12) Septicemia signs, including changes in mentation, tachypnea, and decreased peristalsis, increased pulse, decreased blood pressure, increase or decreased urine output, facial flushing, increased temperature, or malaise were carefully monitored since Harry was very subject to septic shock.

(13) Despite the intense physical pain which Harry experienced with each slight movement, ambulation and physical therapy were necessary to prevent contracture of the scarred tissue and webbing between the fingers and toes.

(14) One of Harry's greatest sources of annoyance and mental anguish began immediately and will continue indefinitely into the future: constant itching. However, the itching has to be endured since scratching will inhibit the growth of newly epithelized tissue and damage skin grafts.

(15) Depression and severe grief over the loss of sense of self and negative disfiguring body image should be treated with appropriate psychological counseling and therapy. However, to date there has been no such treatment since it is not covered under the Canadian health care system.

2. Sepsis

a. Etiology

Harry suffered from bacterial invasions which caused severe, life threatening problems. Gram negative infections are bacterial invasions caused most frequently by escherichia coli, staphylococcus aureus, and klebsiella. The bacteria can invade the bloodstream and the burn victim can rapidly decline into septic and circulatory shock. These bacilli are not invasive in normal persons, however, they are opportunistic bacteria that become infectious in burn victims with diminishing defense mechanisms.

The diagnostic treatment procedures which Harry underwent, such as indwelling catheters, intravenous tubes and oral airways resulted in disruption of the usual protective barriers normally provided by Harry's skin and mucous membranes. The loss of the skin's protective barrier decreased the body's natural immunosuppressive resistance to bacteria. The emergence of antibiotic resistant bacteria added to the extreme difficulty of resolving the infection.

b. Identification

Identification of the appropriate source of Harry's infection was determined by blood cultures taken to identify the etiologic agents. Bronchial washings and sputum were also acquired for pulmonary complications. Tissue cultures were obtained to identify the differing bacterial agents. After considerable testing the sources of the infections were identified and isolated. The antimicrobial agents were timely given and the infection crisis which confronted Harry subsided.

c. Manifestations

Harry was exposed to sepsis and septicemia which manifested as symptoms of fever, chills, flushed skin, deteriorating mental status due to reduction in the oxygenation of the cerebral flow, tachycardia, tachypnea, clammy skin, decreasing pressure, decreased urine output and vascular collapse.

d. Treatment

Harry was constantly monitored for a pattern of the most commonly occurring agents. The presence of catheter tubes, indwelling intravenous and arterial lines, and oral airways increased the avenues of potential infection and Harry's risk factors. Harry's wounds had to be dressed and cleansed frequently to advert the presence of the organism. For a burn patient, dressing and cleansing of wounds is one of the most excruciatingly painful experiences in burning treatment. Harry endured it frequently.

Careful details of Harry's tissue and organ perfusion were made and charted regarding the central venous pressure measurement, left ventricular filling pressure noted through the Swan-Ganz, serum electrolyte levels, urinary output, and deteriorating mental status. Blood or saline were administered for volume expansion to combat vascular collapse. Antibiotics specifically tailored to combat the gram negative infections were administered intravenously.

In addition to the constant fight against life threatening infections, Harry underwent eighteen surgical procedures and will have additional surgeries in the future. The surgical procedures which he has endured to date include the following:

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