I asked the CLNC Pros to describe their most difficult legal nurse consultant job. From a looming deadline to confusing electronic medical records, take a look at how they rose to the challenge of handling these difficult cases.
- Stretches of No Case Involvement
The most difficult legal nurse consultant job I’ve consulted on was a case involving lack of appropriate wound care leading to amputation and eventually death. I worked on the case over a three year period. Sometimes there were months between my involvement, so I had to pick up again where I had left off months earlier. The fact that some of the issues were clouded made my CLNC role even more challenging.To rise to the challenge of this difficult legal nurse consultant job, I kept very detailed notes that I was able to refer to each time I resumed work on the case. I also maintained contact with the attorney even when I was not actively working on the case.
– Dale Barnes, RN, MSN, PHN, CLNC
- Confusing Electronic Medical Records
The most difficult legal nurse consultant job I consulted on involved the PACU and post-op unit care of a teenager who had thyroid surgery. She had a bleeding episode within an hour after surgery resulting in cardiorespiratory arrest.The voluminous and complicated electronic medical record (EMR) made the case challenging. At the time, I did not have the clinical “hands on” knowledge of how one charted on a computer or how the EMR was put together. That was the moment I said to myself, “Marcia, you’re getting outdated as a nurse. Either make a career change so that you can be up-to-date and effective as a Certified Legal Nurse Consultant or continue to be lost in the medical records.”
I was up for the EMR analysis challenge and dug into the records system by system to show that the unit nurse did not assess the patient when she arrived to the unit. I assessed the Activity & Hygiene, Nutrition, Cough/Suction/Sputum, Neuro, Neuromuscular, Vascular, Pulses, Edema, Cardiac, Genitourinary, Musculoskeletal, Braden, Integumentary, Peripheral IV and Pain sections of the chart to show lack of documentation. That totaled up to 15 different sections of the chart that I had to go through! I told myself, “You can do this. You have tackled more difficult things in life.” As Vickie says, “We Are Nurses and We Can Do Anything!®”
That attorney was wowed by my report and extremely complimentary of my thorough investigation of the facts. The win for me – I now understand the EMR.
– Marcia Bell, RN, BSN, CAPA, CLNC
- Difficulty in Locating a Testifying Expert
One of the most difficult legal nurse consultant jobs that I’ve ever consulted on involved a 60-year-old hospice patient, Ms. Olive. This case was about the failure of an infusion company to correctly compound a morphine infusion, which resulted in the concentration being ten times the dosage prescribed. Once the patient received the wrong dosage, her condition quickly declined and she was admitted to an inpatient facility. After Ms. Olive was admitted to the hospital, she was restarted on a morphine drip for comfort measures and expired within 20 hours.The reason this case was difficult was because Ms. Olive was on hospice and was receiving morphine for comfort measures. At the time of her admission to hospice, she was independent in her activities of daily living and her colon cancer was stable. We knew that her hospice admission was a problem for the plaintiff, but the infusion company still failed to correctly compound the morphine, which resulted in her death.
After screening the case, I offered to locate an expert pharmacist for causation. This expert did not support our case. His opinion was that it would be difficult to prove that the excessive morphine dosage was the cause of death, even though the autopsy revealed that she died from acute morphine intoxication. My attorney-client and Mr. Olive were disappointed with his decision and decided to hire another expert. After the second expert would not support the case, Mr. Olive decided not to pursue it.
This confirmed to me that our role as a Certified Legal Nurse Consultant is to give our opinion on whether or not the case has merit. While I felt that the case was meritorious, we could not get an expert opinion to support this opinion.
– Dorene Goldstein, RN, BSN, CLNC
- Limited Availability of Authoritative References
The most difficult legal nurse consultant job I’ve consulted on was my first case for a prominent plaintiff attorney. He was suing the anesthesiologist for malpractice alleging ischemic stroke related to decreased cerebral perfusion associated with the beach chair position during outpatient shoulder surgery.The case was difficult because of the limited availability of authoritative references. One study described four patients – three suffered severe neurologic damage and the fourth died after arthroscopic shoulder surgery in the beach chair position. The authors correlated these outcomes to misinterpretation of blood pressure leading to cerebral hypoperfusion. My attorney-client wanted a detailed report explaining this outcome.
I rose to the challenge of this difficult legal nurse consultant job by thoroughly researching the pathophysiology. I was very familiar with the type of surgery (arthroscopic rotator cuff repair), but I had never been in the OR for a case like this, so I consulted an RN colleague who explained all the specifics about the positioning of the patient and the key details of the surgery. Our conversation about the patient position included IV sites and placement of the BP cuff. The IV must be on the non-operative arm, which then necessitates placing the BP cuff on the calf. I also learned how hypotension is key to maintaining the visual field and the potential success of the surgery and that surgeons get upset when the BP is too high.
Now I was ready to analyze the medical records with focus on the anesthesia and PACU records. I added several visual aides to the report to explain the impact on blood pressure and cerebral perfusion. I used tables in Word and color coding to reinforce not only the patient’s blood pressure readings, but also the length of time her mean arterial pressure was lower than what was required for cerebral perfusion. One table included mathematical adjustments demonstrating that even if she was in the lateral position, her mean arterial pressure was still too low to maintain cerebral perfusion.
My attorney-client was so pleased with the report that he shared it with the anesthesia expert and the tables were used as demonstrative evidence during the trial. I have consulted with this attorney-client for more than ten years now.
– Susan Schaab, RN, BSN, CLNC
- Looming Deadline
My most difficult legal nurse consultant job involved a looming deadline over the holidays from a new attorney-client. While I was looking forward to family, celebration and the much needed down time, the attorney was thinking about the looming statute of limitations deadline. And so, began the most difficult case I’ve ever worked on.I was hoping I could get started with the case after the new year began. I received a summary of the case from the attorney during the initial phone consultation. At that time, she let me know about the looming deadline, the complex nature of the medical malpractice case and the thousands of pages of medical records that I needed to review. I would have to review the case quickly, provide my opinions about the nursing care and work with the attorney to get my opinions documented and filed with the court all before the end of January. There would be no down time during the holidays after all.
I received a banker’s box completely full of medical records and case documents to review. My review of the case began in earnest, and I had many conversations with the attorney-client throughout the holiday season. The case was complex, involving many providers in the emergency department (ED) and intensive care unit of the hospital. The deceased plaintiff had a complex medical history. She frequently accessed medical care in a primary care practice, specialist offices as well as the local ED.
This legal nurse consultant job was difficult because it was a tragic case involving a deceased patient who left behind two young children. One of the pieces of evidence in the case was a photo of the deceased woman in the ED on a stretcher during her final visit and admission to the hospital. The photo was taken by her mother. I had this photo in mind throughout my review of the thousands of pages of medical records.
The decedent had many complex medical problems but died tragically because of the lack of appropriate intervention by the many nursing, ancillary staff and medical providers.
As a Certified Legal Nurse Consultant I have found that cases don’t always arrive at my convenience, however, it’s important to be adaptable. This case changed my holiday plans, but I was happy to consult on it, especially since her children benefitted from my consultation.
– Laura Tucco, RN, PhD, FNP-BC, CNS-BC, CLNC
Thanks to all the CLNC Pros for sharing how they’ve handled these five difficult legal nurse consultant jobs.
Success Is Yours!
P.S. Comment and share how you’ve handled a difficult legal nurse consultant job.
- Stretches of No Case Involvement