The Expert: Dr. Ross Rames, a urologist in Charleston, South Carolina, testifying for the defense and concluding that plaintiff’s problems were not caused by an inappropriate epidural injection.
Testifying in a 2015 medical malpractice trial, Dr. Ross Rames, a Charleston, South Carolina urologist with a special interest in urodynamics, offered his opinion regarding whether a plaintiff’s bladder problems were caused by epidural injections he received from the defendant physician.
Rames first addresses another doctor’s opinion about “autonomic dysreflexia” possibly occurring during epidural injection as a cause of this patient’s difficulties. This condition occurs when the sympathetic nervous system overreacts, resulting in an elevated blood pressure, a significant drop in pulse rate, and a personal feeling of doom. In severe cases, it can result in a stroke. It typically occurs with a high-level, severe spinal cord transection above the T6 level. In this case, there was no catastrophic cord injury. And, although the patient did experience distress with bladder filling, he did not experience concurrent objective changes in either heart rate or blood pressure as would be noted with autonomic dysreflexia.
The expert goes on to note that a cystogram failed to show bladder trebeculations. These are prominent bladder muscle fibers seen on cystoscopy or X-ray studies. Variations in affirming these findings depend upon how filled the bladder is when it is examined. Bladder contraction also appears as trabeculation. It is not a finding specific to any pathologic condition. The expert notes that, in its milder forms, it is not significant and is just a descriptive term.
With regard to the patient’s issues, the expert describes alternatives used for patients who complain of catheter pain. This includes using smaller, more slippery, or different shaped catheters. Also, medications can be used for an anesthetic effect, including pyridium and lidocaine ointment.
Rames goes on to concur with the decisions of multiple urologists who referred the patient back to his pain management doctor after evaluating his catheter pain. He points out that when a patient is on a complex regimen of concurrent pain medicines, it is “best to have one quarterback” for the efficiency of treatment and safety of the patient.
Finally, the doctor details what he sees as the etiology of the patient’s bladder dysfunction. Anesthesia and pain medications postoperatively commonly cause urinary retention. Patients taking many different medications are subject to the effects of polypharmacy. Many medicines can have side effects that hamper normal bladder function. He gives an example of Valium, which affects the nervous system as a whole. Alcohol is another culprit. It depresses the nervous system that controls the bladder. If consciousness is altered to the point of sedation, urine continues to be produced in large amounts due to the diuretic properties of alcohol, but the brain is not aware that the bladder is being distended. If it over-distends enough, the bladder can fail. In clinical practice, the doctor sees this in people whose jobs do not allow them to take a break and they are forced to retain urine. In this case, the expert noted several times when the patient was found to have retained over 1,000 cc of urine. To give perspective on this, he notes that a normal person will urinate 200-300 cc of urine at a time. Over-distention like this can destroy the bladder’s ability to empty on demand.
The expert concludes that he is convinced that it was these conditions that were the factors contributing to the patient’s loss of bladder control and not an inappropriate epidural injection. The jury agreed, ruling for the defense.
Gary Gansar, MD, is residency-trained in general surgery. He served as Chief of Surgery and Staff at Elmwood Medical Center and on the Medical Executive Committee at Touro Infirmary and Mercy Hospital in New Orleans, LA. Dr. Gansar was Board Certified in general surgery while in active practice. He joined AMFS in 2015 as a Physician Medical Director.
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