Monday, December 10, 2018

Dr. Susan Bukata Details an Emergency Amputation, En Route to a $35M Award in a Motorcycle Crash Case

The Trial: Ekbatani v. Caltrans, a personal injury trial over leg injuries a motorcycle rider suffered in a collision with a taxi van.

The Expert: Dr. Susan Bukata, an orthopedic surgeon, testifying for the plaintiff about the injuries he suffered and the need to amputate his leg.

The Verdict: $35 million.


By Gary F. Gansar, MD, FACS; Senior Medical Director, AMFS

 

Dr. Susan Bukata, an expert in orthopedic surgery, presents a calm, authoritative demeanor during this trial describing orthopedic and general surgeons attempting in vain to save an athlete’s leg following a motor vehicle accident. Using graphic detail that likely sends shock waves through a jury of non-medical personnel, she provides a medical expert's insight into the horrible aftermath of a catastrophic crash and helped key an eight-figure verdict against the defendants, which included the California Department of Transportation, or Caltrans. 

Amir “Nick” Ekbatani, a former UCLA football player, suffered a life-threatening leg injury when a taxi van that failed to yield the right-of-way at an intersection struck Ekbatani's motorcycle as it traveled north up the Pacific Coast Highway. Ekbatani sued Caltrans, claiming it knew of safety problems at the intersection but failed to resolve them.

Damages, and importantly, Ekbatani's pain and suffering caused by the crash, served as a key issue of trial. In her testimony, Bukata, an orthopedic surgeon at UCLA Medical Center, describes the operating room scene that would follow Ekbatani's emergency arrival, including a bloody thigh bone sticking through the victim’s skin that requires traction on each side to line the ends up with the other piece of the bone. Reminding the jury that people frequently die from femur fractures by bleeding to death, Bukata describes bringing the ends of the bone together so that they touch, conjuring an uncomfortable sensation in the listener. The orthopedist goes on to describe piercing the soft center of the large femur bone straight through with a large rod holding the two pieces end to end as if it was a “shish kabob,” an image that no one will forget during deliberations.

What everyone knows from her testimony is that the rod that is used is long, extraordinarily long in this case, because of Ekbatani's height. Indeed, Bukata notes that not all hospitals keep rods as long as the one Ekbatani needed. Using a life-sized model, she demonstrates that a hole was drilled into the end of the plaintiff’s thigh bone just above the knee, creating an opening for a guide wire which, along with a “reamer” like a “roto rooter,” will be used to create a path for the huge rod to run through the spongy center of the obviously large bone. Without letting up for a moment, she explains that the large rod placed straight up through the center of the femur is necessary to keep the two ends from “jiggling around”, an expression that, though not quite medical, is something that a cringing jury understands.

Further, she describes the placement of three screws in the bone, “to keep the bones from spinning on each other”. Despite the fact that this patient is asleep, for those who are not acclimated to orthopedic surgery, this whole scene seems tortuous and painful. Implied in the testimony is a key point: if only the accident could have been prevented, this poor patient would not be put through this.

Yet it seems to get worse. Once the femur is aligned, doctors determine that the blood supply to the lower leg has been compromised beyond anyone’s ability to repair it.  Bukata goes through the decision-making process of the two operating surgeons. The lower leg cannot be saved. A below-knee amputation must be performed, but the lower leg’s tissue has been severely damaged by the accident, complicating complicating that procedure. Ultimately this problem will delay completion of the amputation until further operations can be performed. Yes, this patient will have to go through this again and possibly again.

The jury will not be spared a vivid description of this amputation. Bukata explains that without a blood supply, gangrene will develop in the foot and lower leg. There are no pregnant pauses, even when pressed with unanticipated questions from the judge in the case. The doctor’s interaction with the judge is especially informative. She locks her eyes with his, keeping him focused on what she is saying. A description of the terrible specter of dry gangrene as opposed to the life-threatening development of wet gangrene ensues. Again, she gives us the visual of a rotting leg, as “the tissue begins to melt away and the fluid is released from the cells.” In short, without a blood supply, “it’s gonna die.” Just waiting to see if the foot would survive would be an unnecessary threat to this patient’s life.

Communicating as one who is confident in what she is saying, Bukata speaks with this jury, rather than to them, simplifying complex issues in the even tones of expertise. She describes the amputation. On the day of the injury, the doctor may not know how much skin and muscle will survive, so a “Guillotine amputation” must be performed, chopping the leg off and leaving the wound unclosed until the tissues have declared which parts will make it.

With descriptions of saws ripping through bone and scalpels slicing skin, muscle, tendon, and ligament, the whole thing sounds like a war zone, and in the end, she even describes having to put compression on the stump so the dressing is not too bloody. It is a horror story right up to the end, but that is not enough. She details that, not only will the patient have lost his lower leg, but this thigh will be forever 2 ½ inches shorter, making the knee that much higher than the other knee due to surgeries and infection. 

Bukata’s comfort level in the center stage of a courtroom hanging on her every word speaks to extensive operative and courtroom experience facilitating an air of certitude, without a hint of the bombastic. This expert offers plain spoken, accurate, confident testimony that makes the jury feel the patient’s pain and horror. With her final statements, she presents the ultimate nightmare that this patient experienced. He had no idea that his leg might be taken. He was unstable. This surgery was done to save his life. Further, he had to have surgery without the mental preparation that the usual amputee would be afforded. He was sedated, semi-conscious. When he woke up, his leg was gone, and his recovery was just beginning. 

Bukata's contribution to the $35 million judgment in this case should not be minimized.

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Gary Gansar, MD, is residency trained and Board Certified in General Surgery. He previously served as Chief of Surgery and Staff at Elmwood Medical Center and on the Medical Executive Committee at Mercy Hospital and Touro Infirmary in New Orleans, LA. Dr. Gansar also served as Clinical Instructor and Professor of Surgery at Tulane University. He received his MD and served as Chief Resident at Tulane University Medical School. Dr. Gansar joined AMFS as a consulting medical expert in 2011 and has served as Medical Director since Nov. 2015. In this capacity, Dr. Gansar provides consultation, review, and guidance to attorney clients.