Medical Exhibits - Demonstrative Evidence Expert Blog - MediVisuals

By: Robert Shepherd MS, Certified Medical Illustrator, Vice President and Director of Eastern Region Operations,MediVisuals Incorporated

Long before science had advanced to allow imaging of the body in sectional views by computed tomography (CT) and magnetic resonance imaging (MRI), medical illustrators were illustrating the body in sectional views because these views are the best way to appreciate some anatomical relationships. 

Medical illustrators, physicians, and others who have studied anatomy are familiar with sectional views of the body and appreciate the value of these views in explaining the relationship of anatomical structures. However, accomplished and well respected jury consultants and non-medical illustrator legal graphics experts have expressed concerns that sectional views may be difficult for some jury members to understand. These individuals' opinions are valuable to those of us in the legal graphics business, and I agree with their opinions that, when other views can communicate a particular relationship message equally as well or better, sectional views should be avoided. I also believe most of these experts will agree that there are times and places in which sectional views of anatomy are the best way to appreciate some anatomical relationships. Granted, there have been times when we have been working on specific cases and experts have insisted that sectional views be absolutely and unconditionally avoided. Unfortunately, in these situations the experts were unable to suggest a more effective view to communicate the relevant anatomical relationships (at least in a way that was practical in terms of time and expense). That being the case, sometimes the sectional views were used despite the input of the experts, and at other times, the relationships of the structures had to be explained without the benefits of graphics.

A way to perhaps explain how sectional views help decision makers appreciate relevant anatomical and pathological relationships is to compare them to aerial views or photographs of the scene of a collision.  Space is defined in three planes. Only two of these planes can effectively be demonstrated in a two-dimensional rendering. For example, aerial views have long been used to help explain the positions of vehicles and structures that simply can't be appreciate from "street views". When viewing the scene of a collision from a "street view", one can appreciate vertical and horizontal distances, but not depth; distances close to and far from the viewer's perspective are very difficult to appreciate (see the below figures). By comparison, when viewing an operative site through a "surgeon's view", vertical and horizontal distances can be appreciated, but the depth of the incision and the relationships of the various structures within and around the incision are very difficult or impossible to appreciate.

The "aerial view" of the collision scene allows the viewer to appreciate distances in two geographical planes as well (distances right and left, and toward and away from the "street view," but the ability to appreciate up and down is lost). Also, the locations of relevant structures or vehicles that may have been obstructed by nearby structures (such as buildings trees, signs, or other vehicles) can now be appreciated. Similarly, a sectional view of anatomy can help decision makers appreciate depth relationships of structures. Or, a sectional view of a step in a surgical illustration can allow the viewer to appreciate the depth of the surgery as well as the additional structures that may have been injured (or at risk of injury) during the invasive procedure.  These specific depth  relationships could not be appreciated from the "surgeon's view" of the same surgery shown in the above illustration.

Exhibits developed to help explain the invasive nature of a surgery and the disruption of the soft tissues during operative procedures are critical. For that reason, sectional views are critical in aiding a testifying physician to explain these issues. For example, the exhibit panel that demonstrates an anterior cervical discectomy and fusion (ACDF) that does not include a cross-section through the neck fails to emphasize the depth of the incision and disruption of tissues (essentially all the way to the center of the neck). This depth simply cannot be appreciated in a "surgeon's view".

In order to appreciate cross-sections, orientation views that show the level and direction of the section are helpful (see below), or when time, budget, and presentation format (digital as opposed to a physical panel) allow, a short animation showing the sectional view actually coming out of the orientation view such as MediVisuals' "Scan Selector^TM" can be used.

By: Robert Shepherd MS, Certified Medical Illustrator, Vice President and Director of Eastern Region Operations, MediVisuals Incorporated

Individuals who develop new or suddenly worsening symptoms consistent with nerve root or spinal cord impingement following a traumatic event are sometimes diagnosed with “disc-osteophyte complexes”. The term “disc-osteophyte complex” generally refers to abnormal extension of intervertebral disc material that accompanies immediately adjacent osteophyte formation at the vertebral body margin (see the below figure). It is important to note (as shown in the illustrations) that the disc almost always extends further than the osteophytes into the neural foramen or spinal canal to irritate or impinge upon nerve roots or the spinal cord.

Occasionally, individuals who are evaluated shortly after a traumatic event are found to have disc-osteophyte complexes. Because a minimum of several weeks is required for osteophytes to form as a result of a traumatic event, defendant insurance companies may argue that the presence of osteophytes so soon after the traumatic event in question may prove that the plaintiff’s injuries preexisted the traumatic event. Since it is the disc pathology extending beyond the osteophytes that is the actual cause of the nerve root or spinal cord irritation and inflammation, the defense’s arguments are not valid. As shown in the illustrations below, the sequence of events that typically takes place in these cases is that the plaintiff had minimally symptomatic or asymptomatic disc osteophytes prior to the traumatic event in question. During the traumatic event, the disc sustains trauma that results in worsening of the disc pathology while the osteophyte portion of the osteophyte/disc complex remains essentially unchanged. This worsening of the disc pathology in turn results in new or increased irritation or impingement of the neural elements.

By: Delia Dykes, MS

Each year, the Association of Medical Illustrators has a juried Salon at its national conference (this year in Baltimore, at the end of July). Unlike most "art" competitions, the judging criteria are not just based upon the aesthetics of the illustration -- instead, the illustrations are most heavily judged by how well the illustrations communicate a message and upon the illustrations' anatomical and medical accuracy.  MediVisuals was honored once again this year to receive the Award of Excellence and the Award of Merit in Medical Legal illustration.

The below illustration, created primarily by Paul Gross, MS, received the Award of Excellence for effectively demonstrating a surgical procedure to repair severe facial lacerations resulting from a dog bite.  The illustrations were created for Susan M. Bourque of Parker & Scheer, LLC in Boston. The exhibit assisted Parker & Scheer in obtaining a substantial recovery on behalf of the client.

The Association's Award of Merit was bestowed to Cynthia Yoon, MS.BMC, the primary illustrator for a series of three exhibits demonstrating severe facial injuries and surgical repairs resulting from an awning pole from a passing camper flying through the windshield of a vehicle.  The exhibits were developed for William Cunningham of the Burns, Cunningham & Mackey firm in Mobile, Alabama.  The first exhibit shows the initial fractures and external injuries.

The second exhibit demonstrates the chronic left jaw dislocation that ensued after the initial ORIF of the jaw had healed.

The third exhibit highlights the surgical procedure the plaintiff underwent to correct the malunion of the mandible and the left jaw dislocation.

Bob Shepherd, MS, developed the concepts for the illustrations and worked with the illustrators and counsel to help ensure the illustrations met the desired objectives.

By: Robert Shepherd MS, Certified Medical Illustrator, Vice President and Director of Eastern Region Operations, MediVisuals Incorporated

It is now possible for two or more people to simultaneously "share" computers from anywhere in the world through web conferencing. One of the best applications we at MediVisuals have found for this software is to enable the attorney, medical expert and medical illustrator to review and discuss imaging studies simultaneously from their respective offices.

Web conferencing significantly reduces travel time and expense. For example, a recent case required us to team up with a testifying expert located in the Midwest and an attorney in another region. Instead of meeting face-to-face, we tried screen-to-screen contact and found it worked remarkably well. Web conferencing enabled all three of us to maneuver through the imaging studies and move the cursor to specific areas of the films that were being discussed. This, along with simple telephone conferencing, allowed us all to speak with each other as we viewed the same images on our respective computer screens.

Web conferencing makes it easier than ever for us to work with attorneys and medical experts anywhere in the world. The required software programs are simple to use and affordable. The main hurdle involves ensuring the other participants' computers have fast and reliable Internet connections (i.e. DSL or Broadband) and that their web browsers are up-to-date to support the software. Confirming the second/third party Internet and computer capabilities takes no more than a phone call.

Most web conferencing software providers offer a free trial and quick web tutorial, which decreases the learning curve associated with understanding a new program. For the real tech-savvy, some developers even offer applications adaptable to 3G and 4G Smartphones and devices such as the iPad.

If you are interested in introducing web conferencing to your firm, the following is a list of links to recommended software providers’ websites:

Log Me In
http://www.logmein.com

Go To Meeting
http://www.gotomeeting.com

Cisco WebEx
http://www.webex.com/

Yugma
https://www.yugma.com/

MegaMeeting.com
http://www.megameeting.com/

There may be no better measuring stick for an attorney than the opinions of their peers. The same is true for medical illustrators.

During the Association of Medical Illustrators (AMI) Annual Conference, each year a judged illustration competition is held. One of the largest and most competitive categories is the Medical-Legal category. Unlike most art competitions, the illustrations are not judged primarily on aesthetics. Instead, the most important criteria are anatomical accuracy and how effective the visuals are in communicating a stated message to the jury.

At the recent 2010 Conference in Portland, Oregon, the illustrations in the medical-legal category were particularly strong, resulting in the presentation of two Awards of Excellence (the highest honor) and four Awards of Merit. Illustrators with MediVisuals of Richmond, Virginia and Dallas, Texas were honored with both the Awards of Excellence and three of the four Awards of Merit. The various award winning illustrations can be seen by clicking the following link: http://www.medivisuals.com/awards.aspx.

The Award of Excellence in Medical Legal Illustration is particularly significant because this Award has only been bestowed 23 times in the 75 year history of the AMI. With this year’s Awards, MediVisuals has now received 18 of the 23.

MediVisuals was also honored with an Award for a medical-legal animation entitled "Cascade Effect of Axonal Loss". The animation was developed for use in all "mild" TBI cases and helps explain how injury to even one axon can interfere with the ability of several neurons to communicate with each other. The animation can be viewed using the following link or clicking the image below: Cascade Effect of Single Axon Loss Animation

For more information on MediVisuals or to receive a complimentary consultation on an upcoming case, please visit www.medivisuals.com

By: Robert Shepherd, MS, Certified Medical Illustrator, Vice President and Director of Eastern Region Operations, MediVisuals Incorporated

Just as all treating physicians and/or medical experts are not the same, all medical illustrators are not the same. Attorneys typically go to great lengths to ensure that testifying experts for their cases are adequately credentialed, but many give little thought to applying the same due diligence when selecting a medical illustrator. This can be a big mistake because unlike many “professionals”, there is no basic training, licensing, or certification process that is required for an individual to call themselves a “medical illustrator”. Many less skilled and/or less qualified “medical illustrators” market to attorneys – perhaps because attorneys are less able to detect errors in their work. For these reasons, it is the responsibility of the attorney and/or medical expert to their clients to ensure they enlist the services of a medical illustrator who is qualified to provide those services.

Working with a qualified medical illustrator who has experience in the medical-legal area can be a pleasant, enjoyable experience for the testifying expert as these medical illustrators are able to read and comprehend medical records, review imaging studies, and discuss complicated anatomical and medical terms on a very similar level as the expert. On the other hand, working with an un- or minimally qualified and/or inexperienced medical illustrator can be a frustrating and time consuming task that may require multiple revisions of drafts, ineffective demonstrative aids, or even embarrassment during a hearing because of the discovery of some error or inconsistency during testimony.

It can be difficult to determine the qualifications of a medical illustrator based upon looking at their artwork alone. A copy of a résumé or curriculum vitae should be requested. One of the most basic requirements that the résumé should show would include graduation from one of the below medical illustration graduate programs. There are several medical illustration programs in colleges and various institutes in North America and across the globe; however, only five are currently accredited by the American Medical Association, and Commission on Accreditation of Allied Health Education Programs. Those programs include:

• Medical College of Georgia - Master of Science in Medical Illustration

• University of Illinois at Chicago - Master of Science in Biomedical Visualization

• Johns Hopkins University - Master of Arts in Medical and Biological Illustration

• University of Texas, Southwestern – Master of Arts in Biomedical Communications

• University of Toronto - Master of Science in Biomedical Communications

Other criteria that should be evident in a résumé or CV that would help demonstrate at least minimal qualifications are 1) Certification as a medical illustrator as issued by The Board of Certification of Medical Illustrators and 2) Professional Membership in the Association of Medical Illustrators. Both of these require that the individual possess at least minimal medical illustration training and skill levels. Also, just as there are different subspecialties in medicine which require specific and advanced skills and knowledge, specialization in “medical-legal” illustration requires additional knowledge and experience in addition to those required for general medical illustration. For that reason, it is also wise to select a qualified medical illustrator who is not only familiar with illustration and medicine, but also has a significant amount of experience in creating illustrations for litigation purposes.

A very effective way of increasing the effectiveness of expert testimony is by enhancing focus, understanding, and recall by teaming the testifying expert with a qualified medical illustrator, experienced in preparing legal graphics (illustrations, animations, models, etc.). By working together, the medical knowledge and oral skills of the expert can be supported by expertly created medical graphics that greatly clarify complicated anatomical, physiological, and medical subtleties. Together they result in much more effective communication with the decision makers than if verbal testimony or the graphics were used alone (one mode of communication used alone without being supported by the other). In addition, during a period of hours or days of listening to arguments that are typically only verbal, decision makers grasp the opportunity to focus on visuals in the form of illustrations, photographs, models, and/or animations. In fact, information is generally better processed if jury members and other triers of fact can have information presented in a multimodal fashion (i.e. combinations of simultaneous auditory, visual, and tactile stimuli).

The effectiveness of visuals is supported throughout our society by such common phrases as “A picture is worth a thousand words”, and “Seeing is believing.” In addition, numerous manuscripts refer to studies substantiating that recall is greatly increased when the verbal message is supported by visual images. Typically these studies have shown that after varying periods of time information that was delivered by a combination of voice supported by visuals was recalled at a significantly higher percentage than the same message delivered by voice alone.

References

DeBoth, C. J., & Dominowski, R. L. Individual differences in learning: Visual versus
auditory presentation. Journal of Educational Psychology, 1978; Aug 70 (4): 498-503

McCall, J., & Rae, G. Relative efficiency of visual, auditory and combined modes of
presentation in learning of paired-associates. Perceptual and Motor Skills, 1974; June (38) : 955-958.

Multimodal Learning Through Media: What the Research Says. Cisco Web site. http://www.cisco.com/web/strategy/docs/education/Multimodal-Learning-Through-Media.pdf. Accessed August 19, 2008.