Monthly Archives: May 2014

Monthly Case: Greenfield filter with clot

May Newsletter Covered

What is shown? Shown (right photo) is a piece of metal wiring with blood clot trapped in it. The device is called a Greenfield filter. It’s about two inches long altogether. The left picture shows the device where it was found – in the inferior vena cava (dashed lines). The inferior vena has been opened up along its length. The diagrammatic insert shows the filter without clot attached.

What is a Greenfield filter? A Greenfield filter is a device inserted into the inferior vena cava (the large vein returning blood to the heart). The filter traps clot that might travel up from the legs in some patients. It is inserted through the groin and threaded up the inferior vena cava to rest there.

How does the filter stay put? Little hooks at the ends of the wires keep it in place inside the vein. This keeps it from traveling up the vein closer to the heart

How does the filter help the patient? By trapping clots that travel in the blood stream up from the legs, the filter prevents them from traveling any farther. Specifically, the filter prevents them from reaching the lungs. The Greenfield filter saves lives.

Who gets a Greenfield filter? Patients with clots in their legs (deep venous thromboses – DVT’s) get a Greenfield filter.

What was the story here? This was a 32 year old man with cancer (lymphoma), DVT, and many infections. He spent the six months leading up to his death in the hospital.

Why did the family request and autopsy? The family was looking for closure and peace of mind. They were also concerned about the quality of care and the possibility of missed diagnoses. The family was dedicated and committed and had one member or another stay with him at all times. Their style was centered on control with extensive documentation and detailed note-taking of any medical information or conversations that came their way. Behind all this were deep feelings of grief over the loss of a son and brother.

How did the autopsy help? In the setting of deep grief, it was important to make use of any and all information from the autopsy to provide both a clear picture of the quality of care and the patient’s experience prior to death. The finding of a Greenfield filter with entrapped clot indicated the following:

Filter placement. The presence of the filter itself reflected appropriate clinical judgment and excellent quality care on the part of the providers. It is standard of care to place the filter, which is what this patient had. For a family with concerns about treatment, it was then helpful to objectively show that at least in one area (management of deep venous thrombosis), care had been appropriate. This then, could help the family feel a bit less angry about some of their concerns. It was not clear what, if anything, had already been discussed with the family about the filter’s placement. Its finding at autopsy presented another opportunity to review the clinical course.

Trapped clot. The presence of trapped clot indicated a disaster avoided. The amount of clot was significant. Without the filter the clot would have, without a doubt, traveled up the blood stream to the lungs and possibly caused the patient’s death, if not severe illness.

Conclusion. Therefore, for during a life cut short, when days and weeks had become precious to the patient and to the family, it was clear that the medical care had bought some time in this world for this patient. This was an important thing to share with a family dealing with loss; and a benefit of the autopsy.

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Child Abuse Legislation and Reporting

By Candace McPherson (3rd year law student, DePaul University College of Law) and Ben Margolis, M.D. (Director, Autopsy Center of Chicago).

As in other years, 2014 has seen the introduction of bills which protect our children from abuse and neglect. Here are a few:

SB3146 DCFS – Differential Response Programs
This bill mandates and supports ongoing use of Differential Response Programs – a multifaceted approach to child abuse investigation and intervention increasingly in use nationwide.

SB3223 DCFS – Child Abuse – Medical Reports
This bill mandates the timely inclusion of medical records during an investigation by the Department of Children and Family Services (DCFS).

HB5487 DCFS – Abuse Reports – Disabled Kids
This bill provides for the involvement of trained professionals when a DCFS investigation centers on a child with a language disability.

Why are these bills important?
Child abuse is a major social issue. Last year, nearly 3 million cases of child abuse were reported in the United States. However, despite these numbers, child abuse often goes unreported. A study, which was reported in the international journal Child Abuse & Neglect in 2000, showed that 65% of social workers, 58% of physician assistants, and 53% of physicians were not reporting all cases of child abuse. Among the reasons for failing to report incidents included: lack of certainty that abused occurred, community resistance, belief that report would cause additional harm, the need to maintain good relationships with patients and clients, insufficient evidence, and confusion about what types of injuries required reporting. Although experienced in your own profession, you may have similar issues and concerns when it comes to child abuse reporting. It is important to do the right thing.

How are abuse and neglect defined with regards to children? Child abuse is the mistreatment of a child under the age of 18 by a parent, caretaker, someone living in their home or someone who works with or around children. The mistreatment must cause injury or put the child at risk of physical injury. Child abuse can be physical (such as burns or broken bones), sexual (such as fondling or incest), or mental and emotional. Neglect happens when a parent or responsible caretaker fails to provide adequate supervision, food, clothing, shelter, hygiene or other basics for a child.

What happens to abused children? The long-term effects of child abuse can be very damaging to the child being abused or neglected. Common problems for abused children as they age include emotional problems (e.g., low self-esteem and poor self-perception), behavior problems, and poor performance in school and at work. Remember, the effects of child abuse go far beyond the individual child. 95% of child abusers were themselves abused as children. Child abuse can become a vicious cycle across generations.

Who are mandated reporters of abuse and neglect?
The list of mandated reporters is lengthy (please see the Illinois Department of Children and Family Services website). It includes funeral home directors, social workers, physicians, nurses, teachers, school personnel, child care workers, educational advocates, and so on. All are required to take action when there is a concern – either one they perceive or one they learn about.

What are the violations for willful non-report? Willful non-reporting or participation in schemes to prevent revelations of abuse are covered by law as well. Penalties range from Class A misdemeanor to Class 2 Felony depending on the degree of criminal participation and number of prior violations. The penalties are reviewed here (from least severe to most severe):
• Class A misdemeanor – usually results in a fine up to $2,500 and imprisonment in jail up to 12 months, or both.
• Class 4 felony – may include between 1 to 3 years in State Penitentiary and/or a fine up to $25,000.
• Class 3 felony – may include between 2 to 5 years in State Penitentiary; and/or a fine of up to $25,000.
• Class 2 felony – may include between 3 to 7 years in State Penitentiary and/or a fine up to $25,000.

How can a professional participate? Some professionals come into contact with families and children through defined roles which focus on children: pediatricians, teachers, school nurses, and so on. Other professionals interact with adults primarily, but children may be present during these times. For example, funeral directors may see children during the pre-need interaction. Children are often present at a funeral. And so on. Keep your eyes open. See the end of the article for tips on what to look for. If you have a concern, report directly to the Department of Children and Family Services (DCFS) or to a law enforcement agency in the county where the child lives. A majority of reports are initiated by calls from mandated reporters. You are joining many dedicated professionals by reporting if you have a concern.

Where to report? A report of abuse or neglect made to:
DCFS Child Abuse Hotline
(800) 25-ABUSE
(1-800-252-2873)
24/7

The Hotline is located at the Department’s State Central Register in Springfield and is available to take reports of abuse or neglect 24 hours a day, 7 days a week. Anyone may report suspected child abuse or neglect. The report should include the victim’s name and address, the reason that the abuse or neglect is suspected and information about the abuser.

References:
Reporting Child Abuse; Illinois Department of Children and Family Services. Available online.
Child Abuse & Neglect, The International Society for Prevention of Child Abuse and Neglect, North Carolina, 2000.

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GUIDELINES FOR IDENTIFYING CHILD ABUSE AND NEGLECT*
*Modified from: Helpguide.org, A Trusted Non-Profit Resource, Child Abuse & Neglect. Available online


What to look for:


Physical Abuse

Weight change Child is significantly underweight or obese.
Bruising Discoloration of the skin, unusual bruises, unexplained bruises or welts, difficulty walking or sitting.
Burns Multiple burns or in various stages of healing. Look for patterns (e.g., cigarette butt, grid).
Injuries Swellings to the face and extremities, fractures in unusual places, high incidents of accidents or frequent injuries. Injuries which appear to have a pattern such as marks from a hand or belt.
Behavior Shies away from touch and avoids physical contact with others, flinches at sudden movements, apprehensive when other children cry, wears clothing to conceal injury, seems frightened by parents or caregiver and makes strong efforts to avoid a specific person, overly compliant or withdrawn, or seems afraid to go home. Excessively withdrawn, fearful, or anxious about doing something wrong and shows extremes in behavior.

Emotional Abuse The behavioral signs of emotional abuse include negative statements about self, shy, passive, compliant, child lags in physical, mental, and emotional development, highly aggressive, overly demanding, and cruel to others.

Sexual Abuse Walking or difficulty sitting, torn clothing, pain or itching in genital area, venereal disease, or pregnancy. The behavioral signs include inappropriate displays of affection, sexual acting out, sudden use of sexual terms or new names for body parts, sleep problems including insomnia, nightmares, or refusal to sleep without a light, regressive behaviors including thumb-sucking, infantile behaviors, and a sudden change in personality.

Neglect Clothes are ill-fitting, dirty, or inappropriate for the weather (wearing a long-sleeve shirt to cover up injuries on a hot day). Hygiene is consistently bad (unbathed and unwashed hair), untreated illnesses and physical injuries. The child is frequently left unsupervised or alone or is allowed to play in unsafe situations.