The Expert: Dr. Richard Rauck, a North Carolina-based pain specialist, testifies for the defense.
Dr. Richard Rauck, a North Carolina anesthesiologist specializing in pain management, testifies in a 2019 Florida trial concerning the plaintiff’s claim that she had developed complex regional pain syndrome (CRPS) after her foot was run over by a food cart at a Walt Disney World hotel food court. The expert had examined the plaintiff and rendered an opinion for the defense as well as offered thoughts about therapeutic options in this case.
Referring to his notes from her examination, he begins by explaining that she had an antalgic gait, movement that appears unbalanced due to the body’s attempt to minimize pain in one extremity when walking. Having worn a protective boot for three years, Rauck said she was expected to exhibit this symptom and a slight tremor when the boot was removed.
The pain specialist then describes how he tests for allodynia, an increase in painful sensation following normally non-painful stimulation. Using cotton balls or gauze to stroke the extremity, the doctor says responded by complaining of a “scratching sensation,” something that is not typically heard from patients with CRPS. More importantly, he explains that CRPS is usually seen to involve the distal part of the extremity in preference to the proximal aspect, but in this case the opposite seemed to be occurring as the toes were spared from allodynia. Rauck says he did not feel that this made sense, as this is not “how the nerves line up in the body.”
Testing for cold using an alcohol pad, the doctor found that the plaintiff complained of some pain, but not in the classic sense that patients with CRPS typically feel, and again the toes were spared of allodynia. Using a tuning fork to test her vibration sense, he says she related a painful sensation of “lightning bolts.” Rauck felt that it would be unusual in CRPS to have this description for only one type of sensation, particularly for vibration. As well, there was no hyperalgesia—or increased pain sensitivity—at all to the pin prick testing, although she did report a feeling of “scratching.”
The expert also measured the temperature in the patient’s extremities, finding that the affected left extremity was warmer than the right in four of the five areas tested. With CRPS he says that he would have expected the opposite to be true, although after three years, there might be some equilibration.
Measuring the circumference of the calves, Rauck explains that he might expect the affected left calf to be smaller due to atrophic changes, but in this plaintiff, the opposite was seen and the left calf was 3-4% larger in circumference than the right. He also noted no trophic skin changes, such as shiny skin, hair loss on the leg or foot, or discoloration of the legs.
Rauck concludes that the patient suffered from chronic pain in the left lower extremity, but the diagnosis of CRPS did not fit. Instead he characterizes the patient as having “neuropathic pain features… with significant psychological overlay.” This is worsened by the patient’s desire to remain in and rely on the boot, despite being encouraged by those treating her to get out of it.
When asked for his recommendations in treating this woman, he reiterates that she needs to get out of the boot to get her strength and circulation back. More aggressive physical therapy would be useful, he says, as would “cognitive therapy,” which he describes as psychological work to reinforce why she needs to get out of the boot.
He specifically relates that a spinal stimulator would not be useful, noting that she did not seem to want to do this, did not fit the criteria for CRPS, and had waited three years to consider it. He adds that most people who opt for this treatment are in such severe pain that they elect to try this solution much earlier. The fact that she was working was a good sign that she would be functional.
His testimony was essential, as jurors awarded the plaintiff less than $60,000 and found her 60% responsible for the accident.
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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